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• In a cancerous cell, permanent gene alterations, or mutations, cause the cell to malfunction.
• For a cell to become cancerous, usually three to seven different mutations must occur in a single
• These genetic mutations may take many years to accumulate, but the convergence of mutations
enables the cell to become cancerous.
• When the growth factor message reaches the cell nucleus, it activates genes called proto-
oncogenes. These genes produce proteins that stimulate the cell to divide.
• Some oncogenes overproduce growth factors, causing the cell to divide too often. Other
oncogenes stimulate the cell to reproduce even when no growth factor is present.
• Tumor suppressor genes are like brakes for cell growth. When activated, these
genes halt the cell cycle, preventing further cell division.
• But if tumor suppressor genes malfunction due to mutations, the rapidly dividing cell
ignores messages from its neighbors telling it to stop dividing.
• Malfunctioning tumor suppressor genes are not enough to cause cancer—the cell
still must overcome a host of other safety mechanisms before it can cause truly
significant damage.
• Viruses
Prolonged or frequent viral infections may cause breakdown of the immune system or
overwhelm the immune system (Failure of the Immune System Response Theory)
Cancer-causing viruses include the human papilloma virus (HPV), a sexually
transmitted virus responsible for 70 to 80 percent of all cases of cancer of the cervix.
Hepatitis B and C viruses cause almost 80 percent of all liver cancer in the world.
Epstein-Barr virus can also be carcinogenic, causing cancer of the lymphatic system.
Human immunodeficiency virus (HIV) or a type of herpesvirus can lead to rare
cancers of the lymphatic and circulatory systems.
Helicobacter pylori, a bacterium associated with stomach ulcers, likely causes cancer of
the stomach.
• Chemical carcinogens
Acts by causing cell mutation or alteration in cell enzymes and
proteins – altered cell replication
Industrial compounds
Vinyl chloride (plastic manufacture, asbestos factories,
construction works)
Polycyclic aromatic hydrocarbons (burning, auto and
truck emissions, oil refineries), air pollution
Fertilizers, weed killers
Analine dyes
Hair bleach
Tobacco, alcohol
Food, preservatives
Nitrites (bacon, smoked meat)
Food sweeteners
Nitroamines (rubber baby nipples)
Aflatoxins (mold in nuts and grains, milk, cheese, peanut
Polycyclic hydrocarbons (charcoal burning)
• Physical agents
Exposure to electromagnetic radiation, invisible, high-energy light waves such as
sunlight and X rays, accounts for about 2 percent of all cancer deaths
Most cancer deaths from radiation are from skin cancer, which is triggered by too much
sun exposure. Sunlight that reaches the Earth's surface contains two kinds of ultraviolet
(UV) radiation. UV-A and UV-B both contribute to sunburn and skin cancer as well as to
conditions such as premature wrinkling of the skin.
Depletion of the ozone layer, which absorbs ultraviolet radiation in the upper
atmosphere, will continue to increase skin damage and skin cancer rates in the future.
Physical Irritation
• Hormones
In women, relatively high or long exposure to the female sex hormone estrogen seems
to increase the risk of breast and uterine cancers.
Thus, early age at first menstruation, late age at menopause, having children after age
30, and never having children, all of which affect the duration of estrogen exposure in
the body, increase the risk for these cancers.
Some evidence also suggests that estrogen replacement therapy (ERT), in which women
take estrogen to offset the unpleasant effects of menopause, may also increase the risk of
some cancers of the reproductive organs.
The risk appears to go down significantly, however, when estrogen and another female
sex hormone, progesterone, are taken together. At one time studies showed a link
between birth control pills and cancer.
Male sex hormones, particularly testosterone, also appear to play a role in cancers of the
male reproductive organs, but this role is not yet well understood.
• Genetics
Some gene mutations associated with cancer are inherited. For example, inheritance of
the mutated tumor suppressor genes BRCA1 or BRCA2 greatly increases the risk of
breast cancer in young women.
About 50 to 60 percent of women with inherited BRCA1 or BRCA2 mutations will
develop breast cancer by the age of 70. Inherited mutations in the genes MSH2, MLH1,
PMS1, and PMS2, all of which repair DNA, are especially prevalent in a rare form of
hereditary colon cancer.
Scientists suspect that many other hereditary factors contribute to cancer. In addition to
inherited mutations, other genetic variations, particularly those influencing how the body
responds to carcinogens, may create a greater susceptibility to cancer. The identities of
the majority of these genetic variations are not yet known.
• Age
• Sex
Women – more prone to breast, uterus, cervix cancer
Men – more prone to prostate, lung cancer
• Urban VS. Rural residence
Cancer common among urban dweller than rural dwellers
• Geographic distribution
Japan – cancer of the stomach, U.S. – breast cancer
National diet, ethnic customs, type of pollution
• Occupational hazards
Chemical factory workers, farmers, radiology department personnel
• Hereditary
• Stress
• Precancerous lesions
• Obesity
o If any of these abnormal bowel complaints last more than a few days,
they require evaluation.
A – sore that does not heal
U – unusual bleeding or discharge
U – unexplained sudden weight loss
U – unexplained anemia
T – thickening or lump in the breast or elsewhere
o Lumps may represent cancer or a swollen lymph gland related to cancer.
o A lump or gland that remains swollen for 3-4 weeks should be evaluated.
I – indigestion or difficulty in swallowing
O – obvious change in wart or mole
N- nagging cough or hoarseness of voice
o Anyone with a cough that lasts more than a month or with blood in the
mucus that is coughed up should see a doctor.
• Cancer cells divide and grow without control or order to form a mass of tissue, called a
growth or tumor. As the tumor grows, it can invade nearby organs and tissues. Cancer
cells can also break away from the tumor and enter the bloodstream or lymphatic system.
By moving through the bloodstream or lymphatic system, cancer can spread from the
primary site to form new tumors in other organs. The spread of cancer is called
Cancer can be considered a chronic disease requiring ongoing management, rather than a
terminal illness. It consists of more than 100 different conditions characterized by uncontrolled
growth and spread of abnormal cells. Normal mechanisms of growth and proliferation are
disturbed which results in distinctive morphologic alterations of the cell and aberrations in tissue
Metastasis Present
Recurrence Extremely unusual when Common following surgery
surgically removed
Capsule Encapsulated Not encapsulated
Stages of cancer:
Once a stage is assigned and treatment given, the stage is never changed. For
If a stage I cancer of the cervix is treated, and two years later a metastasis is found
in the lung, it is not now stage IV, but remains a "stage I, with recurrence to the
lung." However, some cancers may be re-staged.
The important thing about staging is that it determines the appropriate treatment,
provides a prognosis, and allows for comparison of treatment results between
different treatments.
The T category describes the original (primary) tumor. The tumor size is usually measured in
centimeters (2 and 1/2 centimeters is about 1 inch) or millimeters (10 millimeters = 1
The N category describes whether or not the cancer has reached nearby lymph nodes.
The M category tells whether there are distant metastases (spread of cancer to other parts of
Summary staging
This system is used for all types of cancer. It groups cancer cases into five main categories:
• In situ is early cancer that is present only in the layer of cells in which it began.
• Localized is cancer that is limited to the organ in which it began, without
evidence of spread.
• Regional is cancer that has spread beyond the original (primary) site to nearby
lymph nodes or organs and tissues.
• Distant is cancer that has spread from the primary site to distant organs or
distant lymph nodes.
• Unknown is used to describe cases for which there is not enough information to
indicate a stage.
• The grade of the cancer reflects how abnormal the cancer cells look under the
• Grade is important because cancers with more abnormal-looking cells tend to
grow and spread more quickly.
• Higher grade cancers (meaning that the cancer cells look very abnormal) usually
have a worse prognosis, and sometimes need different treatments.
• The American Joint Committee on Cancer (AJCC) recommends the following
cancer grading classifications:
The types of tests used for staging depend on the type of cancer.
• Imaging studies produce pictures of areas inside the body. These studies are
important tools in determining stage. Procedures such as x-rays, computed
tomography (CT) scans, magnetic resonance imaging (MRI) scans, and
positron emission tomography (PET) scans can show the location of the
cancer, the size of the tumor, and whether the cancer has spread.
• Laboratory tests are studies of blood, urine, other fluids, and tissues taken from
the body. For example, tests for liver function and tumor markers (substances
sometimes found in increased amounts if cancer is present) can provide
information about the cancer. (PSA)
• Pathology reports may include information about the size of the tumor, the growth of the
tumor into other tissues and organs, the type of cancer cells, and the grade of the tumor
(how closely the cancer cells resemble normal tissue). A biopsy (the removal of cells or
tissues for examination under a microscope) may be performed to provide information
for the pathology report (Fine-needle aspiration (FNA) is used most commonly to
differentiate between solid and cystic masses. It is inexpensive, causes little discomfort,
and can be performed in an outpatient or office setting. ). Cytology reports also
describe findings from the examination of cells in body fluids.
• Surgical reports tell what is found during surgery. These reports describe the
size and appearance of the tumor and often include observations about lymph
nodes and nearby organs.
A. Proliferation of Cancer cells
Distention of organs/vessels
C. Anorexia-Cachexia Syndrome
Ca cells produce anorexigenic substances that act on the
satiety center of the hypothalamus, causing anorexia
Radiation therapy is the use of high-energy ionizing rays to destroy a cancer cell's ability
to grow and multiply.
The goal of radiation therapy is to deliver a precisely measured dose of irradiation to a
defined tumor volume with minimal damage to surrounding healthy tissue.
This results in eradication of tumor, high quality of life, prolongation of survival, and
allows for effective palliation or prevention of symptoms of cancer, with minimal
Goals of Therapy
• Curative: When there is a probability of long-term survival after adequate therapy; some
adverse effects of therapy, although undesirable, may be acceptable.
• Palliative: When there is no hope of survival for extended periods, radiation can be
used to palliate symptoms, primarily pain. Lower doses of irradiation (75% to 80% of
curative dose) can control the tumor and palliate symptoms without excessive toxicity.
Principles of Therapy
• Higher doses of irradiation produce better tumor control. For every increment of
irradiation dose, a certain fraction of cells will be killed.
• A boost is the additional dose administered through small portals to residual disease.
• Radiosensitivity is the degree and speed of response. This measure of susceptibility of
cells to injury or death by radiation depends on cancer diagnosis and its inherent biologic
• Role of oxygen: Oxygen must be present at the time of radiation's maximal killing effect.
Poor circulation with resultant hypoxia can reduce cellular radiosensitivity.
• Cellular response can be modified by changing the dose rate, manipulating the process
of cell repair, and using hyperthermia (above 104° F , 40° C]).
• Radioresistance is the lack of tumor response to radiation because of tumor
characteristics (slow-growing tumor, less responsive), tumor cell proliferation, and
circulation. Radiation is most effective during the mitotic stage of the cell cycle.
• Radioresistant tumors: Many tumors are resistant to radiation, such as squamous cell,
ovarian, soft tissue sarcoma. Many other tumors can become resistant after a period of
• Normal radioresistant tissues include mature bone, cartilage, liver, thyroid, muscle,
brain, and spinal cord.
A. Brachytherapy
Radiation is delivered in a high dose to a small tissue volume with less radiation
to adjacent normal tissue, but requires direct tumor access.
B. Teletherapy
is external beam irradiation and uses a device located at a distance from the
It produces X-rays of varying energies and is administered by machines a
distance from the body 31½ to 39 inches (80 to 100 cm).
• Skin effects: fibrosis, telangiectasia, permanent darkening of the skin, and atrophy
• GI effects: fibrosis, adhesions, obstruction, ulceration, and strictures
• Oral effects: permanent taste alterations, and dental caries
• Pulmonary effects: fibrosis
• Renal and bladder effects: radiation nephritis, fibrosis
• Second primary cancer: patients who have received combined radiation and chemotherapy with
alkylating agents have a rare risk of developing acute leukemia
Nursing Assessment
Nursing Diagnoses
• Risk for Impaired Skin Integrity, Infection, Hemorrhage, Stomatitis related to radiation
• Ineffective Protection related to brachytherapy
Nursing Interventions
• Inform the patient that some skin reaction can be expected, but that it varies from patient
to patient. Examples include dry erythema, dry desquamation, wet desquamation, and
• Do not apply lotions, ointments, or cosmetics to the site of radiation unless prescribed.
• Discourage vigorous rubbing, friction, or scratching because this can destroy skin cells.
• Avoid wearing tight-fitting clothing over the treatment field; prevent irritation by not using
rough fabric such as wool and corduroy.
• Take precautions against exposing the radiation field to sunlight and extremes in
• Do not apply adhesive or other tape to the skin.
• Avoid shaving the skin in the treatment field.
• Use lukewarm water only and mild soap when bathing.
Preventing Infection
Preventing Hemorrhage
• To avoid exposure to radiation while the patient is receiving therapy, consider the
o Time - exposure to radiation is directly proportional to the time spent within a
specific distance to the source. (limit contact for 5 minutes each time, a total of
30 minutes per shift)
• If exposed to penetrating radiation (X-ray or gamma rays), wear film badges on the front
of the body.
• Take appropriate measures associated with sealed sources of radiation implanted within
a patient (sealed internal radiation).
o Follow directives on precaution sheet that is placed on the charts of all patients
receiving radiotherapy.
o Do not remain within 3 feet (1 meter) of the patient any longer than required to
give essential care.
• Do not linger longer than necessary in giving patient care, even though all precautions
are followed.
• Be alert for implants that may have become loosened (those inserted in cavities that
have access to the exterior); for example, check the emesis basin following mouth
care for a patient with an oral implant.
• Notify the radiation therapist of any implant that has moved out of position.
• Use long-handled forceps or tongs and hold at arm's length when picking up any
dislodged radium needle, seeds, or tubes. Never pick up a radioactive source with
your hands.
• Do not discard dressings or linens unless you are sure that no radioactive source is
• After the patient is discharged from the hospital, it is a good policy for the radiologist to
check the room with a radiograph or survey meter to be certain that all radioactive
materials have been removed.
• Continue radiation precautions when a patient has a permanent implant, until the
radiologist declares precautions unnecessary.
Chemotherapy is the use of antineoplastic drugs to promote tumor cell destruction by
interfering with cellular function and reproduction. It includes the use of various
chemotherapeutic agents and hormones.
Personal Safety to Minimize Exposure via Inhalation
• Wrap gauze or alcohol pads around the neck of ampules when opening to decrease
droplet contamination.
• Wrap gauze or alcohol pads around injection sites when removing syringes or needles
from I.V. injection ports.
• Do not dispose of materials by clipping needles or removing needles from syringes.
• Use puncture- and leak-proof containers for non-capped, non-clipped needles.
• Wear nitrile examination gloves at all times when preparing or working with
chemotherapeutic agents.
• Wash hands before putting on and after removing gloves.
• Change gloves after each use, tear, puncture, or medication spill or after every 60
minutes of wear.
• Wear a long-sleeve, nonabsorbent gown with elastic at the wrists and back closure.
• Eye and face shields should be worn if splashes are likely to occur.
• Use syringes and I.V. tubing with Luer locks (which have a locking device to hold needle
firmly in place).
• Label all syringes and I.V. tubing containing chemotherapeutic agents as hazardous
• Place an absorbent pad directly under the injection site to absorb any accidental
• If any contact with the skin occurs, immediately wash the area thoroughly with soap and
• If contact is made with the eye, immediately flush the eye with water and seek medical
• Spill kits should be available in all areas where chemotherapy is stored, prepared, and
• Do not eat, drink, chew gum, or smoke while preparing or handling chemotherapy.
• Keep all food and drink away from preparation area.
• Wash hands before and after handling chemotherapy.
• Avoid hand-to-mouth or hand-to-eye contact while handling chemotherapeutic agents or
body fluids of the person receiving chemotherapy.
• Discard gloves and gown into a leak-proof container, which should be marked as
contaminated or hazardous waste.
• Use puncture- and leak-proof containers for needles and other sharp or breakable
• Linens contaminated with chemotherapy or excreta from patients who have received
chemotherapy within 48 hours should be contained in specially marked hazardous waste
• Wear non-sterile nitrile gloves for disposing of body excreta and handling soiled linens
within 48 hours of chemotherapy administration.
• In the home, wear gloves when handling bed linens or clothing contaminated with
chemotherapy or patient excreta within 48 hours of chemotherapy administration. Place
linens in a separate, washable pillow case. Wash separately in hot water and regular
The cause of fatigue is generally unknown but can be related to anemia, weight loss, altered
sleep patterns, and coping.
• Caused by the stimulation of the vagus nerve by serotonin released by cells in the upper
GI tract.
• Incidence depends upon the particular chemotherapeutic agent and dosage.
• Patterns of nausea and vomiting:
o Anticipatory - conditioned response from repeated association between therapy
and vomiting.
o Acute - occurs 0 to 24 hours after chemotherapy administration.
o Delayed - can occur 1 to 4 days after chemotherapy administration.
• Caused by suppression of the stem cell or interference with cell proliferation pathways.
• May require red blood cell transfusion or injection of erythropoietin
• Patient should be taught to avoid injury, eg, no razors, avoid vaginal douches and rectal
suppositories, and avoid dental floss during the period of thrombocytopenia.
• May require platelet transfusions if count drops below 20,000/mm3.
Hypersensitivity Reactions
Nursing Assessment
Integumentary System
GI System
• Assess for frequency, timing of onset, duration, and severity of nausea and vomiting
episodes before and after chemotherapy.
o Usually occurs from 1 to 24 hours after chemotherapy but may be delayed.
Anticipatory vomiting may occur after first course of therapy. Can be initiated by
various cues, including thoughts, smell, or even sight of the medical personnel.
• Observe for alterations in hydration, electrolyte balance.
• Assess for diarrhea or constipation.
o Ascertain any changes in bowel patterns.
o Discuss the consistency of stools.
o Consider the frequency and duration of diarrhea (the number of stools each day
for the number of days).
• Assess for anorexia.
o Discuss taste changes and changes in food preferences.
o Ask about daily food intake and normal eating patterns.
• Assess for jaundice, right upper quadrant abdominal pain, changes in the stool or urine,
and elevated liver function tests that indicate hepatotoxicity.
• Monitor liver function tests and total bilirubin.
Hematopoietic System
o Assess for signs of bleeding (including nose, urinary, rectal, or hemoptysis).
o Assess for blood in stools, urine, or emesis.
o Assess for signs and symptoms of intracranial bleeding if platelet count is less
than 20,000/mm3; monitor for changes in level of responsiveness, vital signs, and
pupillary reaction.
• Assess for anemia.
o Assess skin color, turgor, and capillary refill.
o Ascertain whether patient has experienced dyspnea on exertion, fatigue,
weakness, palpitations, or vertigo. Advise rest periods as needed.
Nursing Diagnoses
Nursing Interventions
Preventing Infection
• Monitor vital signs every 4 hours; report occurrence of fever greater than 101° F (38.3°
C) and chills.
• Provide patient education.
o Instruct patient to report signs and symptoms of infection:
Fever greater than 101° F and/or chills
Mouth lesions, swelling, or redness
Redness, pain, or tenderness at rectum
Change in bowel habits
Areas of redness, swelling, induration, or pain on skin surface
Pain or burning when urinating or odor from urine
Cough or shortness of breath
o Reinforce good personal hygiene habits (routine bathing [preferably a shower],
clean hair, nails, and mouth care).
o Avoid contact with people who have a transmissible illness.
o Encourage deep breathing and coughing to decrease pulmonary stasis.
• Avoid performing invasive procedures - rectal temperatures, enemas, or insertion of
indwelling urinary catheters.
• Monitor white blood cell count (WBC) and differential.
• Administer prophylactic antibiotics as prescribed (if WBC is less than 500).
Preventing Bleeding
• Avoid invasive procedures when platelet count is less than 50,000/mm3, including I.M.
injections, suppositories, enemas, and insertion of indwelling urinary catheters.
• Apply pressure on injection sites for 5 minutes.
• Monitor platelet count; administer platelets as prescribed.
• Monitor and test all urine, stools, and emesis for blood.
Minimizing Fatigue
Promoting Nutrition
Minimizing Stomatitis
• Encourage the use of oral agents to promote cleansing, debridement, and comfort.
Mouthwashes with more than 25% alcohol should be avoided.
• Assess the need for antifungal, antibacterial, or antiviral therapy (each infection has a
different appearance).
• Administer local oral therapy such as combinations with viscous lidocaine (Xylocaine) for
symptomatic control and maintenance of calorie intake.
• Be alert for signs of allergic reactions such as pruritus, urticaria, and difficulty breathing,
as well as back pain. Situation may worsen suddenly to hypotension and anaphylaxis.
• Stop the medication or infusion immediately, notify the health care provider, and monitor
the patient closely. Treatment is supportive and dependent on type of reaction and its
o Do not administer the agent again if there was a severe reaction resulting in
significant hypotension.
o Premedicate the patient with antihistamine or corticosteroid as directed if there is
a history of moderate reaction.
• Reassure patient that hair will usually grow back; however, it may grow back a different
texture or different color.
• Suggest wearing a turban, wig, or headscarf, preferably purchased before hair loss
occurs. Many insurance companies will pay for a wig with a prescription.
• Encourage patient to stay on therapeutic program.
• Be honest with the patient.
• Make sure that patient uses good hygiene, knows symptoms of infection to report, and
avoids crowds and people with infection while neutropenic.
• Advise patient to avoid using a razor blade to shave, contact sports, manipulation of
sharp articles, use of hard bristle toothbrush, and passage of hard stool to prevent
bleeding while thrombocytopenic.
• Advise women to report symptoms of vaginal infection due to opportunistic fungal or viral
• Encourage patient participation in plan for chemotherapy and to set realistic goals for
work and activities.
• Assure patient that changes in menses, libido, and sexual function are usually temporary
during therapy.
Cancers of the thyroid, oral cavity, skin, lymph nodes, testes, and ovaries
General cancer-related Every three years for people aged 20 to 40; yearly after age 40
physical examination
Colorectal cancer
Stool examination for the Yearly after age 50
presence of occult (hidden)
One of the following:
Sigmoidoscopy Every five years after age 50
examination and digital
rectal examination
Colonoscopy and digital Every ten years after age 50
rectal examination
Double-contrast barium Every five to ten years after age 50
enema and digital rectal
Prostate cancer
Digital rectal examination Yearly after age 50
Cervical cancer
Pelvic examination and Pap Yearly for women who are or have been sexually active or have
smear reached age 18. After three or more consecutive normal exams,
a Pap smear may be performed less frequently at the
physician's discretion.
Breast cancer
Breast self-examination Monthly after age 20
Breast examination by a Every three years for women aged 20 to 40; yearly after age 40
Mammography Yearly after age 40
Source: American Cancer Society.
The breasts are made of fat, glands, and connective (fibrous) tissue. The breast has several
lobes, which are divided into lobules that end in the milk glands. Tiny ducts run from the many
tiny glands, connect together, and end in the nipple.
• These ducts are where 80% of breast cancers occur. This condition is called ductal
• Cancer developing in the lobules is termed lobular cancer. About 10-15% of breast
cancers are of this type.
• Other less common types of breast cancer include inflammatory breast cancer,
medullary cancer, phyllodes tumor, angiosarcoma, mucinous (colloid) carcinoma, mixed
tumors, and a type of cancer involving the nipple termed Paget's disease.
• In situ is Latin for "in place" or "in site" and means that the changes haven't spread from
where they started.
• When these in situ changes occur in the ducts, they are called ductal carcinoma in situ
(DCIS). DCIS may be identified on routine mammography.
• When in-situ changes happen in the lobules, it is called lobular carcinoma in situ (LCIS).
When cancers spread into the surrounding tissues, they are termed infiltrating cancers. Cancers
spreading from the ducts into adjacent spaces are termed infiltrating ductal carcinomas.
Cancers spreading from the lobules are infiltrating lobular carcinomas.
The most serious cancers are metastatic cancers. Metastasis means that the cancer has spread
from the place where it started into other tissues distant from the original tumor site. The most
common place for breast cancer to metastasize is into the lymph nodes under the arm or above
the collarbone on the same side as the cancer. Other common sites of breast cancer metastasis
are the brain, the bones, and the liver.
Many women who develop breast cancer have no risk factors other than age and sex.
• Gender is the biggest risk because breast cancer occurs mostly in women.
• Age is another critical factor. Breast cancer may occur at any age, though the risk of
breast cancer increases with age. The average woman at age 30 years has one chance
in 280 of developing breast cancer in the next 10 years. This chance increases to one in
70 for a woman aged 40 years, and to one in 40 at age 50 years. A 60-year-old woman
has a one in 30 chance of developing breast cancer in the next 10 years.
• White women are slightly more likely to develop breast cancer than African American
women in the U.S.
• A woman with a personal history of cancer in one breast has a three- to fourfold greater
risk of developing a new cancer in the other breast or in another part of the same breast.
This refers to the risk for developing a new tumor and not a recurrence (return) of the
first cancer.
Genetic Causes
Family history has long been known to be a risk factor for breast cancer. Both maternal and
paternal relatives are important. The risk is highest if the affected relative developed breast
cancer at a young age, had cancer in both breasts, or if she is a close relative. First-degree
relatives, (mother, sister, daughter) are most important in estimating risk. Several second-
degree relatives (grandmother, aunt) with breast cancer may also increase risk. Breast cancer
in a male increases the risk for all his close female relatives. Having relatives with both breast
and ovarian cancer also increases a woman's risk of developing breast cancer.
There is great interest in genes linked to breast cancer. About 5-10% of breast cancers are
believed to be hereditary, as a result of mutations, or changes, in certain genes that are passed
along in families.
• BRCA1 and BRCA2 are abnormal genes that, when inherited, markedly increase the risk
of breast cancer to a lifetime risk estimated between 40 and 85%. Women with these
abnormal genes also have an increased likelihood of developing ovarian cancer. Women
who have the BRCA1 gene tend to develop breast cancer at an early age.
• Testing for these genes is expensive and may not be covered by insurance.
• The issues around testing are complicated, and women who are interested in testing
should discuss this with their health-care providers.
Hormonal Causes
Hormonal influences play a role in the development of breast cancer.
• Women who start their periods at an early age (11 or younger) or experience a late
menopause (55 or older) have a slightly higher risk of developing breast cancer.
Conversely, being older at the time of the first menstrual period and early menopause
tend to protect one from breast cancer.
• Having a child before age 30 years may provide some protection, and having no children
may increase the risk for developing breast cancer.
• Oral contraceptives have not been shown to definitively increase or decrease a woman's
lifetime risk of breast cancer.
• A large study conducted by the Women's Health Initiative showed an increased risk of
breast cancer in postmenopausal women who were on a combination of estrogen and
progesterone for several years. Therefore, women who are considering hormone
therapy for menopausal symptoms need to discuss the risk versus the benefit with their
health-care providers.
• This link is thought to be an environmental influence rather than genetic. For example,
Japanese women, at low risk for breast cancer while in Japan, increase their risk of
developing breast cancer after coming to the United States.
• Several studies comparing groups of women with high- and low-fat diets, however, have
failed to show a difference in breast cancer rates.
• Fibrocystic breast changes are very common. Fibrocystic breasts are lumpy with some
thickened tissue and are frequently associated with breast discomfort, especially right
before the menstrual period. This condition does not lead to breast cancer.
• However, certain other types of benign breast changes, such as those diagnosed on
biopsy as proliferative or hyperplastic, do predispose women to the later development of
breast cancer.
Environmental Causes
Radiation treatment increases the likelihood of developing breast cancer but only after a long
delay. For example, women who received radiation therapy to the upper body for treatment of
Hodgkin disease before 30 years of age have a significantly higher rate of breast cancer than
the general population.
• Most breast lumps are not cancerous. All breast lumps, however, need to be evaluated
by a doctor.
• Nipple inversion is a common variant of normal nipples, but nipple inversion that is a
new development can be of concern.
• Changes in the skin of the breast include redness, changes in texture, and puckering.
These changes are usually caused by skin diseases but occasionally can be associated
with breast cancer.
Women older than 20 years should perform monthly breast self-examinations (BSE). If you still
have menstrual periods, you should perform the examination a few days after your period has
ended. During this time, your breasts are not tender. If you are not menstruating (such as in
menopause), BSE should be performed on the same day each month.
Use the following techniques to perform a BSE. Choose the method that is best for you.
Facing a mirror
Stand before a mirror and compare both breasts for differences in size, nipple inversion (turning
in), bulging, or dimpling. Note any skin or nipple changes, such as a hard knot or nipple
o With your hands on hips - Press firmly to flex your chest muscles.
Lying down
• Right breast
o Check the entire breast area with the finger pads of your left hand.
o Use light, medium, and firm pressure over each area of the breast.
o Feel the breast with the surfaces of the second, third, and fourth fingers, moving
systematically and using small, circular motions from the nipple to the outer
• Left breast
o Repeat these steps on your left breast using your right hand.
In the shower
• A BSE can easily be performed while you're in the bath or shower. Some women
discover breast masses when their skin is moist.
o With soapy hands and fingers flat, check your right breast.
o Use the same small circles and up-and-down pattern described earlier.
o Repeat on the left breast.
Breast cancer develops over months or years. Once it is identified, however, a certain sense of
urgency is felt about the treatment, because breast cancer is much more difficult to treat as it
spreads. You should see your health-care provider if you experience any of the following:
• Finding a lump in your armpit or above your collarbone that does not go away in two
weeks or so
• You should see your health-care provider within the next 24 hours because infection
should be treated promptly.
• If you have redness, swelling, or severe pain in the breast and are unable to reach your
health-care provider, a trip to the nearest emergency department is warranted.
If an abnormality is found on your mammogram, you should see your health-care provider right
away to make a plan for further evaluation.
Diagnosis of breast cancer usually is comprised of several steps, including examination of the
breast, mammography, possibly ultrasonography or MRI, and, finally, biopsy. Biopsy is the only
definitive way to diagnose breast cancer.
Examination of the Breast
• A complete breast examination includes visual inspection and careful palpation (feeling)
of the breasts, the armpits, and the areas around your collarbone.
• During that exam, your health-care provider may palpate a lump or just feel a thickening.
Begin by looking at your breasts in the mirror with your shoulders straight and your arms on
your hips.
Here's what you should look for:
If you see any of the following changes, bring them to your doctor's attention:
• A nipple that has changed position or become inverted (pushed inward instead of
sticking out).
While you're at the mirror, gently squeeze each nipple between your finger and thumb and
check for nipple discharge (this could be a milky or yellow fluid or blood).
Feel your breasts while lying down, using your right hand to feel your left breast and then your
left hand to feel your right breast. Use a firm, smooth touch with the first few fingers of your
hand, keeping the fingers flat and together.
Cover the entire breast from top to bottom, side to side—from your collarbone to the top of your
abdomen, and from your armpit to your cleavage.
Finally, feel your breasts while you are standing or sitting. Many women find that the easiest
way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the
shower. Cover your entire breast, using the same hand movements described in Step 4.
• Mammograms are x-rays of the breast that may help define the nature of a lump.
Mammograms are also recommended for screening to find early cancer.
• Usually, it is possible to tell from the mammogram whether a lump in the breast is breast
cancer, but no test is 100% reliable. Mammograms are thought to miss as many as 10-
15% of breast cancers.
• A false-negative mammogram is one that appears normal when in fact cancer is present.
• A mammogram alone is often not enough to evaluate a lump. Your health-care provider
will probably request additional tests.
A. Normal left mammogram with motion blur. Compression of the breast is
necessary in order to minimize the chance of blurring or fuzziness that may
hide a cancer.
B. Normal left mammogram without motion blur. This is the same view of the
same patient, performed with adequate breast compression that has
immobilized the breast. The image is sharp and therefore cancer is easier to
• The only way to diagnose breast cancer with certainty is to biopsy the tissue in question.
Biopsy means to take a very small piece of tissue from the body for examination and
testing by a pathologist to determine if cancer is present. A number of biopsy techniques
are available.
• Fine-needle aspiration consists of placing a needle into the breast and sucking out
some cells to be examined by a pathologist. This technique is used most commonly
when a fluid-filled mass is identified and cancer is not likely.
• Core-needle biopsy is performed with a special needle that takes a small piece of tissue
for examination. Usually the needle is directed into the suspicious area with ultrasound
or mammogram guidance. This technique is being used more and more because it is
less invasive than surgical biopsy. It obtains only a sample of tissue rather than
removing an entire lump. Occasionally, if the mass is easily felt, cells may be removed
with a needle without additional guidance.
• Surgical biopsy is done by making an incision in the breast and removing the piece of
tissue. Certain techniques allow removal of the entire lump.
• Regardless of how the biopsy is taken, the tissue will be reviewed by a pathologist.
These are physicians who are specially trained in diagnosing diseases by looking at
cells and tissues under a microscope.
• If a cancer is diagnosed on biopsy, the tissue will be tested for hormone receptors.
Receptors are sites on the surface of tumor cells that bind to estrogen or progesterone.
In general, the more receptors, the more sensitive the tumor will be to hormone therapy.
• Staging in breast cancer is based on the size of the tumor, which parts of the breast are
involved, how many and which lymph nodes are affected, and whether the cancer has
metastasized to another part of the body.
• Cancers may be referred to as invasive if they have spread to other tissues. Those that
do not spread to other tissues are called noninvasive. Carcinoma in situ is a noninvasive
• Stage 0 is noninvasive breast cancer, that is, carcinoma in situ with no affected lymph
nodes or metastasis. This is the most favorable stage of breast cancer.
• Stage I is breast cancer that is less than 2 cm (3/4 in) in diameter and has not spread
from the breast.
• Stage II is breast cancer that is fairly small in size but has spread to lymph nodes in the
armpit OR cancer that is somewhat larger but has not spread to the lymph nodes.
• Stage III is breast cancer of a larger size, greater than 5 cm (2 in), with greater lymph
node involvement, or of the inflammatory type.
• Stage IV is metastatic breast cancer: a tumor of any size or type that has metastasized
to another part of the body. This is the least favorable stage
Medical Treatment
Many women have treatment in addition to surgery, which may include radiation therapy,
chemotherapy, or hormonal therapy. The decision about which additional treatments are
needed is based upon the stage and type of cancer, the presence of hormonal and/or HER-
2/neu receptors, and patient health and preferences.
Radiation therapy is used to kill tumor cells if there are any left after surgery.
• Radiation is a local treatment and therefore works only on tumor cells that are directly in
its beam.
• Radiation is used most often in people who have undergone conservative surgery such
as lumpectomy. Conservative surgery is designed to leave as much of the breast tissue
in place as possible.
• Radiation therapy is usually given five days a week over five to six weeks. Each
treatment takes only a few minutes.
• Radiation therapy is painless and has relatively few side effects. However, it can irritate
the skin or cause a burn similar to a bad sunburn in the area.
External Radiation
The most common type of radiation is known as external beam. In this technique, a large
machine called a linear accelerator delivers high-energy radiation to the affected area. The
linear accelerator creates high-energy radiation to treat cancers, using electricity to form a
stream of fast-moving subatomic particles. You'll receive this form of radiation as an outpatient
in daily sessions over five to seven weeks, depending on your particular situation.
Woman in position for external beam radiation treatment, from the front. Middle radiation
beam is shown.
Woman in position for radiation treatment, from the side. Side radiation treatment beam
is shown.
D Arm holder
E Heart
F Lungs
G Backbone
H Sternum/breastbone
As indicated in these photos, radiation to the whole breast is delivered from two different
treatment fields. The two fields come from opposite directions, which face each other:
• One starts from the side of the breast and faces the middle of the chest (where the
breastbone is).
• One starts in the middle of the chest and faces the side.
The radiation oncologist can maximize the amount of radiation delivered to the breast area and
avoid or minimize radiation to other parts of the body by:
• treating the breast area with angled fields that skim across the chest, just catching the
breast area,
• placing the back edges of the two fields as close to the breast area as possible,
• using special blocks in the head of the machine to avoid radiation to normal tissue, and
• placing special devices, called wedges, in the path of the beam to bend the dose of
radiation away from normal tissues under the breast.
Partial-breast Radiation
Most women with early-stage breast cancer are able to have breast-conserving surgery
(lumpectomy) followed by radiation instead of mastectomy—with the same chances of a good
long-term outcome.
Lumpectomy removes the cancer. Then radiation is given to get rid of any cancer cells that
might be left behind after the main cancer has been removed.
The current standard of care is to treat the whole breast with radiation after lumpectomy. But
another option is available: partial-breast radiation. It's also known as partial-breast irradiation
(PBI) or limited-field radiation therapy. Researchers are studying partial-breast radiation to see
how the benefits compare to whole-breast radiation.
Partial-breast radiation was developed to reduce recurrence, shorten the length of time it takes
to get radiation treatment, and limit the dose of radiation (and associated side effects) to
surrounding normal tissue. Partial-breast radiation also MAY be able to be given again— but
only to another part of the breast—if a new breast cancer is diagnosed in the future. Whole-
breast radiation usually can't be given again to the same breast.
A number of studies on women with early-stage breast cancer have compared lumpectomy
alone to lumpectomy and whole-breast radiation. The results showed that whole-breast
radiation after lumpectomy reduces the risk of recurrence by about two thirds.
The area that's very close to the site of the original cancer is the area that's at highest risk of
recurrence. The risk of cancer coming back in a different part of the same breast is quite low.
This is true whether you have lumpectomy alone or lumpectomy followed by whole-breast
Based on these findings, doctors created a new radiation approach: focus the radiation only on
the area near where the cancer was. Treating an area smaller than the whole breast can be
done in less time (one week versus six to seven weeks).
The early results from the first small studies on partial-breast radiation look very promising.
These results have led to the next step: comparing partial-breast radiation to whole-breast
radiation, which is the current standard of care. The NSABP B-39 clinical trial, which is
comparing these two treatments, is looking at:
• overall survival (how long the women lived, with or without the cancer coming back)
• recurrence-free survival (how many women lived with the cancer never coming back)
• distant disease-free survival (how long the women lived before the cancer came back)
The study is also looking at quality of life issues, including fatigue, treatment-related side
effects, and convenience of the treatments.
There are different ways to deliver partial-breast radiation. It is usually given internally (from the
inside). But it can also be given externally (from the outside) during or after surgery.
In the past, the most common way to give partial-breast radiation was to put very tiny pieces of
radioactive material called seeds into hollow tubes that were placed in the treatment area. Now
the most popular methods are internal radiation using the MammoSite balloon device, and
external radiation using small fields from a linear accelerator (a large machine that creates the
radiation for treatment). Internal radiation delivered at the time of surgery, called intraoperative
radiation, is done in relatively few treatment centers.
Internal radiation is also called brachytherapy. "Brachy" means slow delivery using radioactive
seeds (compared to regular external beam radiation, which delivers radiation faster using a
machine). There are two kinds of brachytherapy: multi-catheter brachytherapy and balloon-
catheter brachytherapy.
In multi-catheter brachytherapy tiny tubes (catheters) are sewn under your skin in the area
where the cancer was. The ends of the tubes stick out through little holes in the skin. Tiny
stitches hold the tubes in place.
Radioactive seeds are then placed into the tubes just long enough to deliver the prescribed
dose. If slow-delivery radiation seeds are used, the treatment can take a few days. During
treatment, you stay in the hospital because there is radioactivity inside you. Special precautions
are taken to keep you and everyone else safe. Your nurses, doctors, and visitors are allowed to
be with you for only a short time while the radiation seeds are in the tubes. No one will be able
to be very close to you. Once the treatment is done, the radioactive seeds, the stitches, and the
tubes are removed. Then you can go home.
If high-dose radioactive seeds are used, each seed might be left in for up to 10 minutes. Once
treatment is done, the tubes are removed.
In balloon-catheter brachytherapy (the MammoSite system), a special tube with a balloon on the
end is used. The balloon is placed into the area where the cancer was. The tube comes out
through a little hole in the skin. Stitches aren't needed because the balloon is filled with fluid to
hold the balloon and tube snugly in place. The MammoSite can be inserted in an operating
room or in a surgeon's office. The balloon stays in place about a week and a half.
Careful planning is done to make sure that the balloon fits into the breast properly. During each
treatment, a radioactive seed is placed into center of the balloon for about 5 to 10 minutes—just
long enough to deliver the prescribed dose of radiation. A total of 10 treatments usually are
given over five days. That means two treatments per day, about six hours apart. When the final
treatment is done, the balloon is removed through the small hole in the skin.
Partial-breast radiation can be given during lumpectomy surgery, after the cancer has been
removed. While the underlying breast tissue is still exposed, a single dose of radiation is given
directly to the area where the cancer was.
One way uses the linear accelerator to deliver electron beam radiation to the area where the
cancer was. Radiation with electrons only goes a short distance and can be concentrated on the
area at risk. Special techniques are used to protect the underlying tissue. The procedure takes
about two minutes and then the surgery is completed as usual.
The other technique is known as the high-dose rate remote afterloading intraoperative radiation
technique. This procedure uses a small tube to deliver a high dose of radiation to the area
where the cancer was. The tube is put into position and then connected to a computerized
radiation machine. The procedure takes about 5 to 10 minutes. For safety reasons, all the
doctors and nurses must leave the room while the radiation is delivered. But a special patient
monitoring station is located outside the operating room so your doctors watch and check on
you the whole time.
Only a few treatment centers offer radiation during surgery. There are several reasons why:
• Using intraoperative radiation for partial-breast radiation is very new. Only small studies
with short follow-ups have been done so far.
• Intraoperative partial-breast radiation hasn't been compared to the standard of care:
whole-breast radiation after lumpectomy.
• It's very expensive to have a radiation machine and proper shielding in an operating
room. Most radiation therapy departments are far away from the operating rooms, so the
equipment can't be shared or moved.
Only a few very small studies with very little follow-up have been done on giving partial-breast
radiation externally after surgery. This treatment approach starts with a planning session
(simulation). A special CAT scan of the breast is done and is used to map out small treatment
fields for the area at risk. The type and distribution of radiation is designed to maximize the dose
to the area that needs to be treated and avoid or minimize radiation to tissue near the area. The
radiation is delivered with a linear accelerator, twice a day for one week.
Brachytherapy is one type of radiation therapy used to treat cancer. Radiation therapy is the use
of a type of energy, called ionizing radiation, to kill cancer cells and shrink tumors.
Unlike external beam therapy (EBT), in which high-energy x-ray beams generated by a machine
are directed at the tumor from outside the body, brachytherapy involves placing a radioactive
material directly inside the body.
Brachytherapy, also called internal radiation therapy, allows a physician to use a higher total
dose of radiation to treat a smaller area and in a shorter time than is possible with external
radiation treatment.
In temporary brachytherapy, the radioactive material is placed inside or near a tumor for a
specific amount of time and then withdrawn. Temporary brachytherapy can be administered at a
low-dose rate (LDR) or high-dose rate (HDR). Low-dose rate brachytherapy is also used in the
treatment of coronary artery disease to prevent restenosis after angioplasty. (For more
information, see "Radiation of the Heart: A Novel Treatment for Coronary Artery Narrowing After
Balloon Angioplasty.")
Permanent brachytherapy, also called seed implantation, involves placing radioactive seeds or
pellets (about the size of a grain of rice) in or near the tumor and leaving them there
permanently. After several weeks or months, the radioactivity level of the implants eventually
diminishes to nothing. The seeds then remain in the body, with no lasting effect on the patient.
Chemotherapy consists of the administration of medications that kill cancer cells or stop them
from growing. In breast cancer, three different chemotherapy strategies may be used:
1. Adjuvant chemotherapy is given to people who have had curative treatment for their
breast cancer, such as surgery and radiation. It is given to reduce the possibility that the
cancer will return.
2. Presurgical chemotherapy is given to shrink a large tumor and/or to kill stray cancer
cells. This increases the chances that surgery will get rid of the cancer completely.
Most chemotherapy agents are given through an IV line, but some are given as pills.
• Chemotherapy is usually given in "cycles." Each cycle includes a period of intensive
treatment lasting a few days or weeks followed by a week or two of recovery. Most
people with breast cancer receive at least two, more often four, cycles of chemotherapy
to begin with. Tests are then repeated to see what effect the therapy has had on the
• Chemotherapy differs from radiation in that it treats the entire body and thus may target
stray tumor cells that may have migrated from the breast area.
• The side effects of chemotherapy are well known. Side effects depend on which drugs
are used. Many of these drugs have side effects that include loss of hair, nausea and
vomiting, loss of appetite, fatigue, and low blood cell counts. Low blood counts may
cause patients to be more susceptible to infections, to feel sick and tired, or to bleed
more easily than usual. Medications are available to treat or prevent many of these side
Hormonal therapy may be given because breast cancers (especially those that have ample
estrogen or progesterone receptors) are frequently sensitive to changes in hormones. Hormonal
therapy may be given to prevent recurrence of a tumor or for treatment of existing disease.
• Until recently, tamoxifen (Nolvadex), an antiestrogen (a drug that blocks the effect of
estrogen), has been the most commonly prescribed hormone treatment. It is used both
for breast cancer prevention and for treatment.
• Fulvestrant (Faslodex) is another drug that acts via the estrogen receptor, but instead of
blocking it, this drug eliminates it. It can be effective if the breast cancer is no longer
responding to tamoxifen. Fulvestrant is only given to women who are already in
menopause and is approved for use in women with advanced breast cancer.
• Aromatase inhibitors, which block the effect of a key hormone affecting the tumor, may
be more effective than tamoxifen in the adjuvant setting. The drugs anastrozole
(Arimidex), exemestane (Aromasin), and letrozole (Femera) have a different set of side
effects and risks than tamoxifen.
• Aromatase inhibitors are rapidly moving into first line hormonal therapy regimens. In
addition, they are frequently used after two or more years of tamoxifen therapy.
• Megace (megestrol acetate) is a drug similar to progesterone which may also be used
as hormonal therapy.
Monoclonal antibodies are antibodies against proteins in or around a cancer cell. Antibodies
recognize an "invader"—in this case, a cancer cell—and attack it.
• Lapatinib (Tykerb) is another drug that targets the HER2/neu protein and may be given
combined with chemotherapy. It is used in women with HER2-positive breast cancer that
is no longer helped by chemotherapy and trastuzumab.
• Another monoclonal antibody, Bevacixumab (Avastin) has been shown to have activity in
the treatment of breast cancer and is used in combination with chemotherapy. This drug
targets the ability of cancers cells to form new blood vessels.
Surgery is generally the first step after the diagnosis of breast cancer. The type of surgery is
dependent upon the size and type of tumor and the patient's health and preferences.
• Lumpectomy involves removal of the cancerous tissue and a surrounding area of normal
tissue. This is not considered curative and should almost always be done in association
with other therapy such as radiation therapy with or without chemotherapy or hormonal
• At the time of lumpectomy, the axillary lymph nodes (the glands in the armpit) need to be
evaluated for the spread of cancer. This can be done by either removing the lymph
nodes or by sentinel node biopsy (biopsy of the closest lymph node to the tumor).
• If a sentinel node biopsy is done at the time of lumpectomy, it may allow the surgeon to
remove only some of the lymph nodes. In this procedure, a dye is injected into the area
of the tumor. The path of the substance is then followed as it travels to the lymph nodes.
The first node reached is the sentinel node. This node is considered most important to
biopsy when evaluating the spread of the tumor.
• If the sentinel node biopsy is positive, the surgeon will usually remove of all of the lymph
nodes found in the axilla (armpit).
• Simple mastectomy removes the entire breast but no other structures. If the cancer is
invasive, this surgery alone will not cure it. It is a common treatment for DCIS, a
noninvasive type of breast cancer.
• Modified radical mastectomy removes the breast and the axillary (underarm) lymph
nodes but does not remove the underlying muscle of the chest wall. Although additional
chemotherapy or hormonal therapy is almost always offered, surgery alone is
considered adequate to control the disease if it has not metastasized.
• Radical mastectomy involves removal of the breast and the underlying chest wall
muscles, as well as the underarm contents. This surgery is no longer done because
current therapies are less disfiguring and have fewer complications.
Mastectomy Overview
Mastectomy is an operation in which the entire breast, usually including the nipple and the
areola, is removed. Mastectomy is usually performed as a treatment of breast cancer.
In general, women with breast cancer can decide whether to be treated with a lumpectomy or a
A lumpectomy is the removal of the cancerous breast tissue as well as a surrounding rim of
healthy breast tissue. A lumpectomy is a breast-conserving surgery that is usually followed by
radiation therapy (high-dose x-rays or other high-energy rays to kill cancer cells).
A woman may decide to have a mastectomy versus a lumpectomy based on the following:
• If the tumor is big and, after the lumpectomy, very little breast tissue would remain
• If she does not want to undergo radiation therapy after the surgery
• If she believes she will have less anxiety about a recurrence of breast cancer with a
If the woman has tumors in more than one quadrant of the breast, most cancer doctors
recommend a mastectomy.
Historically, a mastectomy for breast cancer included an axillary lymph node dissection (removal
of many of the axillary lymph nodes). Over the last decade, the approach has changed slightly
in that many women can undergo a sentinel lymph node biopsy (removal of the first few lymph
nodes draining the tissue of the breast) rather than an axillary lymph node dissection. The
nomenclature is such that a modified radical and a radical mastectomy include an axillary lymph
node dissection as part of the overall procedure. With the adoption of sentinel lymph node
biopsy in the treatment of early breast cancer, the nomenclature for mastectomy has also
changed. Depending on the characteristics of the tumor, the breast, and the patient, the
surgeon may choose one of the following types of mastectomies:
• Simple or total mastectomy: The surgeon removes the entire breast tissue but does not
remove the muscle tissue under the breast. This mastectomy can be combined with a
sentinel lymph node biopsy in any case of an early invasive cancer and in some cases of
ductal carcinoma in-situ when a mastectomy is chosen as the treatment option. Any of
these can also be combined with an axillary lymph node dissection (which by convention
turns the total mastectomy into a "modified radical mastectomy"). There are several
subtypes of simple or total mastectomy depending on how much skin is removed.
o Traditional: The surgeon removes an ellipse of skin that includes the skin of the
nipple/areolar complex. This is the most commonly performed mastectomy. If the
woman doesn't want immediate reconstruction or is not offered immediate
reconstruction, the end result is a flat chest with a scar about 8 inches in length,
usually oriented transversely.
o Skin-sparing: In addition to the breast tissue as noted, the only skin removed is
that of the nipple and areola, usually through a circular incision around the
areola. If the breast is large, the surgeon may have to make a "keyhole" incision
(one that includes a straight incision in one direction, generally down) to allow
removal of the breast tissue.
o Nipple-sparing: The surgeon makes an incision around the nipple but leaves the
areola intact. Again, in order to remove all of the breast tissue, the incision will
need to be bigger than what is achieved with removal of the nipple. This is often
an S-shaped incision.
o Total skin-sparing: The surgeon removes the breast tissue but leaves all the skin
(including the skin of the nipple and areola) behind. The incision can be place in
the outer part of the breast, in the inframammary fold or around the areola.
In general, if leaving the skin of the areola and or nipple, some surgeons recommend that the
woman have a tumor that is less than 2 centimeters in size and that is more than 2 centimeters
away from the nipple. The skin-sparing mastectomies are ideal for patients undergoing
prophylactic mastectomy. The skin-sparing, nipple-sparing, and total skin-sparing mastectomies
are generally done in combination with immediate breast reconstruction. The benefit of these
procedures is that more of the breast skin envelope is preserved to make it easier to recreate
the breast. No randomized trial has been undertaken to evaluate if there is an increased risk of
local (in the breast skin or on the muscle) recurrence with the skin-sparing techniques. Most
surgeons estimate that preserving more skin increases the risk of local recurrence of the tumor
by 1% or 2 % over 20 years (from 3%-5% for traditional to 5%-7% for skin-sparing).
• Modified radical mastectomy: This combines a simple or total mastectomy, including the
skin of the nipple and the areola, and includes removal of most of the lymph nodes in the
armpit (axillary nodes) using a 6- to 8-inch incision. A woman undergoing a modified
radical mastectomy can have immediate or delayed breast reconstruction.
• Radical mastectomy: The surgeon removes the entire breast tissue, all the lymph nodes
in the armpit, and the muscles of the chest wall (pectoral muscles) that lie under the
affected breast. Radical mastectomy was common in the past; however, it is rarely
performed now.


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subset: commoncrawl


text:
Most Cited Applied Numerical Mathematics Articles
The most cited articles published since 2014, extracted from Scopus.
A new Jacobi rational-Gauss collocation method for numerical solution of generalized pantograph equationsE. H. Doha | A. H. Bhrawy | D. Baleanu | R. M. Hafez
Volume 77, January 2014, Pages 43-54
A cut finite element method for a Stokes interface problemPeter Hansbo | Mats G. Larson | Sara Zahedi
Volume 85, January 2014, Pages 90-114
An improved collocation method for multi-dimensional space–time variable-order fractional Schrödinger equationsA. H. Bhrawy | M. A. Zaky
Volume 111, January 2017, Pages 197-218
A weighted finite difference method for the fractional diffusion equation based on the Riemann-Liouville derivativeErcília Sousa | Can Li
Volume 90, January 2015, Pages 22-37
A modified quasi-boundary value method for an inverse source problem of the time-fractional diffusion equationTing Wei | Jungang Wang
Volume 78, April 2014, Pages 95-111
Error estimates for the moving least-square approximation and the element-free Galerkin method in n-dimensional spacesXiaolin Li
Volume 99, January 2016, Pages 77-97
Legendre spectral collocation method for neutral and high-order Volterra integro-differential equationYunxia Wei | Yanping Chen
Volume 81, January 2014, Pages 15-29
Carleman estimates for the regularization of ill-posed Cauchy problemsMichael V. Klibanov
Volume 94, January 2015, Pages 46-74
The numerical solution of weakly singular integral equations based on the meshless product integration (MPI) method with error analysisPouria Assari | Hojatollah Adibi | Mehdi Dehghan
Volume 81, July 2014, Pages 76-93
Error estimates for the interpolating moving least-squares method in n-dimensional spaceF. X. Sun | J. F. Wang | Y. M. Cheng | A. X. Huang
Volume 98, December 2015, Pages 79-105
Analysis of the element free Galerkin (EFG) method for solving fractional cable equation with Dirichlet boundary conditionMehdi Dehghan | Mostafa Abbaszadeh
Volume 109, November 2016, Pages 208-234
Efficient implementation of RKN-type Fourier collocation methods for second-order differential equationsBin Wang | Fanwei Meng | Yonglei Fang
Volume 119, September 2017, Pages 164-178
Finite element approximation with numerical integration for differential eigenvalue problemsSergey I. Solov'Ëv
Volume 93, January 2015, Pages 206-214
Krylov subspace recycling for sequences of shifted linear systemsKirk M. Soodhalter | Daniel B. Szyld | Fei Xue
Volume 81, January 2014, Pages 105-118
Reconstruction of implicit curves and surfaces via RBF interpolationSalvatore Cuomo | Ardelio Galletti | Giulio Giunta | Livia Marcellino
Volume 116, June 2017, Pages 157-171
Analysis of a multi-frequency electromagnetic imaging functional for thin, crack-like electromagnetic inclusionsWon Kwang Park
Volume 77, January 2014, Pages 31-42
L∞ error estimates of discontinuous Galerkin methods for delay differential equationsDongfang Li | Chengjian Zhang
Volume 82, January 2014, Pages 1-10
Trefftz discontinuous Galerkin methods for acoustic scattering on locally refined meshesRalf Hiptmair | Andrea Moiola | Ilaria Perugia
Volume 79, January 2014, Pages 79-91
An efficient semi-implicit finite volume method for axially symmetric compressible flows in compliant tubesMichael Dumbser | Uwe Iben | Matteo Ioriatti
Volume 89, January 2015, Pages 24-44
Efficient and accurate spectral method using generalized Jacobi functions for solving Riesz fractional differential equationsZhiping Mao | Sheng Chen | Jie Shen
Volume 106, August 2016, Pages 165-181
Parallel multilevel solvers for the cardiac electro-mechanical couplingP. Colli Franzone | L. F. Pavarino | S. Scacchi
Volume 95, May 2015, Pages 140-153
Anisotropic hp-adaptive method based on interpolation error estimates in the Lq-normVít Dolejší
Volume 82, January 2014, Pages 80-114
IMEX schemes for pricing options under jump-diffusion modelsSanttu Salmi | Jari Toivanen
Volume 84, January 2014, Pages 33-45
Spectral element technique for nonlinear fractional evolution equation, stability and convergence analysisMehdi Dehghan | Mostafa Abbaszadeh
Volume 119, September 2017, Pages 51-66
Solving a class of nonlinear boundary integral equations based on the meshless local discrete Galerkin (MLDG) methodPouria Assari | Mehdi Dehghan
Volume 123, January 2018, Pages 137-158


text:
Find Dog Grooming in Linlithgow on the Linlithgow Journal and Gazette directory. Get reviews and contact details for each business including phone number, postcode, opening hours and photos.
5 Pardovan Holdings, Linlithgow, West Lothian, EH49 6QZ
276b High Street, Linlithgow, West Lothian, EH49 7ER
Thorn House, The Loan, Linlithgow, EH49 6LW
Comfortable, heated and spacious accommodation suitable for single, double or multi-dog families. Open viewing seven days a week...
276B High Street, Linlithgow, West Lothian, EH49 7ER
Unit 3, Stockbridge Retail Park, Linlithgow, West Lothian, EH49 7AS
Dun-Mor, Auldhill Road, Linlithgow, EH49 6NH
Pet Services -> Dog Day Care
72 Forker Avenue, Rosyth, Dunfermline, Fife, KY11 2UF
Mucki Mutz Dog Wear produce a stunning range of uniquely designed dog coats and accessories. They are made to measure and hand...
8 Milrig Holdings, Kirknewton, Midlothian, EH27 8DE
Milrig Farmhouse, 9 Milrig Holdings, Kirknewton, Midlothian, EH27 8DE
111 Main Street, East Calder, West Lothian, EH53 0EP
All Doggy Style products are hand made with high quality fabrics and fittings. Collars, leads, harnesses and other accessories can...
7 Cypress Grove, Dunfermline, Fife, KY11 8AF
We are Dog Walking Dunfermline, a team of experienced dog walkers based in Dunfermline. We have over 5 years experience walking...
70 Stewartfield Crescent, Broxburn, WEST LOTHIAN, EH52 5ER
8 Anderson Lane, Kincardine, Alloa, Clackmannanshire, FK10 4SF
Avonstream, Avonbridge, Falkirk, Stirlingshire, FK1 2JL
97 Birkdale Park, Armadale, Bathgate, West Lothian, EH48 2NF


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Woman who has lived with bullet in throat for 15 years seeking compensation
SEE ALSO :Gilgil residents want KDF shooting range relocated"I gained consciousness 30 minutes later while at the Kisumu International Airport. I heard my husband, Daniel Liboyi, telling me, 'don't leave me now, we are almost to the hospital' and fainted again," she said. Intensive care "I woke up after three days and found myself in the intensive care unit surrounded by doctors and family members. I didn't know I had been shot. One of the doctors told me I was lucky to be alive after being hit by a bullet." She said the doctors told her the bullet had hit her when its momentum was greatly reduced, perhaps after first passing through an obstacle. Mwale said they also told her the bullet was attached to her veins and if it was removed, she would die. "The doctors treated me and I was discharged after a week. The wound healed after three weeks and I became a State witness. Police had arrested one of the five gangsters who survived after being shot." Mwale said the suspect was jailed and she enquired from the police whether she would be compensated, but they were non-committal. She was told to look for an advocate and file a case in court. Since she had no money to start the process and the matter was shelved. "What I want is to be compensated since the bullet that hit me was as a result of police negligence when pursuing the gangsters. I want the National Police Service Commission (NPSC) to compensate me for the pain and suffering I have endured," Mwale said. She also wants the Government to help her and her husband, who is unemployed, to set up another business to enable them to raise their family. Mwale said that after she was shot, her entire stock of slippers and shoes was looted, crippling any further trade. The family spent Sh236,000, savings from her business, to pay the hospital bill, causing the business to collapse. "I now sell maize storage bags to earn a living. I cannot carry heavy loads on my head since it will complicate the situation. My voice has changed and you must be a good listener to hear what I am saying. When it is cold, my body itches and it is very painful," she said. Mwale has four children; two sons and two daughters. Her oldest son, Nicanory Liboyi, is now 23. He remembers coming home from school and hearing that police had shot his mother. Everybody thought she had died but he would later learn that she had survived. Emotionally hurt "We were emotionally hurt but God intervened. But since then, my mother's life has changed. The Government should be compelled to compensate us so that we can go to school," said Nicanory. According to Samuel Simiyu, a surgeon at the Kakamega County Teaching and Referral Hospital, it is possible for a person to have a normal life with a bullet lodged in their body. He told The Standard that if during surgery doctors realised that removing the bullet would result in the patient's death, it would be left. "You can live with a bullet in the spinal cord, brain and even throat. It has no effect on the victim but if she feels it is affecting her, she should seek medical advice," said Dr Simiyu.
For the latest news in entertainment check out Sde.co.ke and Pulser.co.ke , for everything sports visit Gameyetu.co.ke and ladies we have you covered on Evewoman


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The Academy by FOSC is designed for youth players from the ages of 5-8 years old.
The entire emphasis of the Academy is to introduce youth to the game of soccer in a fun, nurturing environment.
Academy members are taught the skills and an appreciation of the "beautiful game" and are encouraged to
utilize and experiment with these skills in both practice and game situations. The Academy program consists
of skill training sessions with our highly respected youth staff. Academy members will also participate in
game situations against players of their own age from other clubs in short-sided games. In these games,
players are given the chance to utilize the foot skills learned throughout the training sessions rather than
pressured to simply win every match.
FOSC aims to provide a stress-free atmosphere to expose young players to the game.
We emphasize skill development in a non-competitive environment that encourages players to flourish
while focusing on skill development. The Academy emphasizes quality and long-term benefits rather than
short-term gain, within an age-appropriate development process.
A Cincinnati native, Justin attended Cincinnati Christian High School and the University of Findlay. Justin has been with FOSC and
the Academy since 2012 and currently serves as a club trainer and Director of the Academy program.
For more information about the Academy, contact: Justin Langhammer [email protected]
All Training will be run by the FOSC Academy staff and will train at the Optimist soccer fields,
The Academy games will be played at the Optimist soccer fields in a 3v3 or 4v4 format. The Academy players will
be broken into teams of 4-5 players (coed). Games will be played on Sunday afternoons.
All participants must register for the academy online at www.foscsoccer.com.
Payment can be made by credit card or by cash/check (payable to FOSC) on the first day of training.
Registration is not complete until your player is registered online and payment is received. All payments must be made prior to the Academy season.
For questions regarding the Spring Academy, please contact Justin Langhammer at [email protected]
P.O. Box 18252 Fairfield, Ohio 45018
Email : [email protected]


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text:
Premiums slump at CNA Re
CNA Re has reported net written premiums for the first quarter of 2001 down by almost half on the first quarter of last year, although net profit for the quarter fell just 14%.
Net written premiums
Net written premiums
Happy Easter everyone!
Sounded a good plan, Exec Team Visit to our wonderful claims team in Morecambe, bit of a 'Back to the Floor' & dish out some Easter Eggs. Lovely. So how did I end up with these & having to wear them home on the train? Thanks @helenidle @AXAUK @AXA_Broker #BunnyEars pic.twitter.com/cNd80WnRPd— David Williams (@AXADavidW) April 17, 2019
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- Customers increasingly looking to credit to pay for premiums: research
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text:
Re: William T. and family
In reply to:
William T. and family
Jo Ann Stephens 7/04/05
William Thomas Argabrite was born 5-27-1910 and died 6-6-1966 in Henderson County, Kentucky. He owned Argabrite Chevrolet in Henderson, Kentucky. His wife, Sara E. Argabrite died 8-7-1993 in Henderson County, Kentucky. I could not bring her up on the SS Death Index for some reason. She was 82 when she died. Best bet for her is to get her death certificate from Frankfort, Kentucky. They are $6. William Thomas is buried with his parents in the Fairmount Cemetery in Henderson County, Kentucky but I don't have a clue where Sara is buried. Doctor Benjamin Green Argabrite (W. T.'s father) lived next door to my Aunt Jessie Howard on Chestnut Street in Greenville, Kentucky. Benjamin Argabrite was born 10-30-1875 in W. VA. and died 6-9-1947 in Greenville, Kentucky. He married Leah Davis. She was born 12-25-1890 and died 10-18-1973 in Muhlenberg County, Kentucky. I don't know anything about William T and Sara's daughter, Theda. I just barely remember the family. Hope this helps.
More Replies:
Re: William T. and family
Jo Ann Stephens 7/15/05
Re: William T. and family
Jo Ann Stephens 7/10/05


text:
Cincin berlian 1049 brlian 0.378crt 4.4 gram
1 year ago by jhonihendra80
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text:
4 dead, including 2 children, in possible murder-suicide in Joliet
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Rusha Brooks on Thursday sat in a living room filled with boxes — a sign, she said, that her daughter was getting ready to move out.
But Jacquelon Gaskin never got that chance.
Gaskin, 28, her boyfriend, Brandyn Lee, and the two small children they shared were found dead in their Joliet home in an apparent murder-suicide.
At 10:19 p.m. Wednesday, officers responded to a call of people shot inside a house in the 500 block of Whitley Avenue, according to Joliet police.
Officers discovered the bodies of a male, a female and two young children on the second story. Investigators said there is no threat to the public.
"It appears at this time to be a murder-suicide," police said. "No one else is being sought in reference to the incident at this time."
The Will County coroner's office said autopsies were scheduled for Friday.
Brooks and the coroner's office identified the children as Gianna Lee, 6, and Giovanni Lee, 1. Brooks said her daughter had been with Lee for about 10 years.
"He was too controlling and she was just unhappy," Brooks said, but added she didn't know her daughter had planned to leave — until she saw the boxes Thursday, after police had removed the yellow crime tape and had allowed the family inside.
"She was an excellent mother to her children. She was loved and adored by many and will be missed dreadfully," Brooks said.
Brooks said her daughter had graduated from Joliet Central High School and was working as a day care assistant. She had plans to study to become a nurse, Brooks said.
Brooks said her last contact with her daughter was when they texted back and forth Wednesday evening, while Brooks was shopping for some boots for her daughter.
"We were laughing about it. We were texting pictures of shoes to each other," Brooks said.
Contributing: Sun-Times Wire


text:
Superhero Cape and Mask Set - Superman/girl
Regular price $15.00
Which superhero do you have living at home? Could it be Superman or even Supergirl? This cape can also be for other of them. Superhero capes are 26" long and have a Velcro closure for easy removal. The little ones can show off their super powers and play as a cape crusader. The mask is blue on one side and red on the other.


text:
Issue 39 – June 2012
Energy Safety has made changes to their website.
The new site features:
- an About section including publications, FAQs, news, and media releases
- a Legislation and Policy area, including links to our governing legislation
- an Appliances and fittings area for manufacturers, importers, suppliers and retailers
- an Installations and Networks area for designers, electrical workers, gas workers and users of electrical and gas installations and distribution systems
- a Consumer section, including safety alerts
- a Forms section, including complaint and fault forms, approved practitioner application, declaration and exemption forms, and the Event Notification form.
Go to the Energy Safety web site(link http://www.med.govt.nz/energysafety)


text:
Where will your retirement money come from? If you're like most people, qualified-retirement plans, Social Security, and personal savings and investments are expected to play a role. Once you have estimated the amount of money you may need for retirement, a sound approach involves taking a close look at your potential retirement-income sources.
Retiring the 4% Rule
A portfolio created with your long-term objectives in mind is crucial as you pursue your dream retirement.
Investment Strategies for Retirement
Investment tools and strategies that can enable you to pursue your retirement goals.
Have A Question About This Topic?
The Cost of Procrastination
Don't let procrastination keep you from pursuing your financial dreams and goals.
Social Security: The Elephant in the Room
Some people wonder if Social Security will remain financially sound enough to pay the benefits they are owed.
IRA Withdrawals that Escape the 10% Tax Penalty
The list of IRA withdrawals that may be taken without incurring a 10% early penalty has grown.
What Is a Stretch IRA?
If you have a traditional IRA, you may have the opportunity to extend its tax-deferred status across multiple generations.
Volunteering in Retirement
For many, retirement includes contributing their time and talents to an organization in need.
What Is a Roth 401(k)?
Roth 401(k) plans combine features of traditional 401(k) plans with those of a Roth IRA.
View all articles
Self-Employed Retirement Plans
Estimate the maximum contribution amount for a Self-Employed 401(k), SIMPLE IRA, or SEP.
A Look at Systematic Withdrawals
This calculator may help you estimate how long funds may last given regular withdrawals.
Roth 401(k) vs. Traditional 401(k)
This calculator compares employee contributions to a Roth 401(k) and a traditional 401(k).
Saving for Retirement
This calculator can help you estimate how much you may need to save for retirement.
Annuity Comparison
This calculator compares a hypothetical fixed annuity with an account where the interest is taxed each year.
My Retirement Savings
Estimate how long your retirement savings may last using various monthly cash flow rates.
View all calculators
An Inside Look at Retirement Living
A number of questions and concerns need to be addressed to help you better prepare for retirement living.
Retirement Plan Distributions
There are a number of ways to withdraw money from a qualified retirement plan.
Investment Strategies for Retirement
Investment tools and strategies that can enable you to pursue your retirement goals.
View all presentations
Women and Retirement
Women must be ready to spend, on average, more years in retirement than men.
RE: Retirement
How does your ideal retirement differ from reality, and what can we do to better align the two?
Retirement Redefined
Around the country, attitudes about retirement are shifting.
Rightsizing for Retirement
What does your home really cost?
Tuning Your Social Security Benefit
When should you take your Social Security benefit?
Social Security: By the Numbers
Here are five facts about Social Security that might surprise you.


text:
Send greetings to loved ones with the friendly forest creatures in this set of delightful boxed notecards. It's the perfect gift for animal lovers. Our best-selling QuickNotes are smaller than notecards but large enough to convey personal greetings thank-yous and invitations. 20 notecards 5 each of 4 images. 20 envelopes. Magnetic closure. Sturdy reuseable box ideal for keepsakes.
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28 Collection Of Complete Circuit Drawing High Quality Free Circuit Diagram Year 2 Circuit Diagram Bbc Bbc Bitesize Electrical Circuits #4551
Carrying out electrical wiring by on your own might be tricky. This is certainly particularly so whenever you absence the expertise as well as the knowledge in electrical stuff. The matter is you can not do a trial and error system when dealing with electrical wiring. Errors could price you a fortune or perhaps your life. That is definitely why prior to starting off any do-it-yourself electrical repair, you will need to request some electrical wiring concerns only to be certain you already know what you're doing. One thing about electrical wiring is the fact that wires are frequently coloration coded. Hence, it is actually much easier to find out which ones go along with which. Beneath would be the most popular electrical wiring questions whose responses commonly contain hues that will help you discover every distinct wire. - 10 Band Graphic Equalizer Circuit Diagrams
Electronic Ballast Circuit Diagram Electrical Wiring Diagrams Electronic Fluorescent L Ballast Circuit Diagram Wiring Electronic Philips Electronic Ballast Circuit Diagram Electronic Ballast Circuit Diagram Electronic Choke Circuit Diagram For 40w Tube Light #601
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How do You Wire a Switch?
Among essentially the most typical electrical wiring thoughts is regarding how to wire a change. Even though employing switches at your home is kind of uncomplicated, wiring 1 may not be that easy for everybody. An ON-OFF switch is in fact quite simple to wire. You will discover several types of switches, but for this instance, let's say you happen to be setting up a single-pole toggle switch, a really popular change (and the most basic).
You can find three hues of wires within a usual single-pole toggle switch: black, white, and inexperienced. Splice the black wire in two and connect them over the terminal screws - a person on major as well as other on the base screw with the switch. The white wire serves being a resource of uninterrupted electric power and is commonly linked to some gentle colored terminal screw (e.g., silver). Hook up the environmentally friendly wire into the ground screw of your respective swap.
These methods would typically be adequate to generate a standard change do the job with no trouble. However, should you are certainly not self-confident you can attain the endeavor appropriately and safely and securely you greater allow the professionals do it in its place. Just after all, you will find a purpose why this job is without doubt one of the most commonly encountered electrical wiring inquiries asked by the majority of people.
How do You Wire a Ceiling Fan?
For a few reason, tips on how to wire a ceiling fan is also certainly one of probably the most common electrical wiring thoughts. To simplify this task, you can utilize just one change for just a single ceiling fan. To wire the enthusiast, it truly is just a issue of connecting the black wire in the ceiling fan to the black wire of your change. If there is a light, the blue wire must be related to your black wire on the swap as well.
How can You Replace a Breaker and exactly how Does one Increase a Sub Panel?
When quite a few endeavor to do these tasks by themselves, most of the people are suggested to hire an electrician rather. It can be extra sophisticated and as a consequence dangerous for the majority of people today to test to switch a breaker or add a panel. To give you an strategy about such prevalent electrical wiring queries, you'd really need to perform on the scorching electrical panel. In case you don't even really know what what this means is, you happen to be merely not outfitted to accomplish the task your self. Even though you must expend a lot more by hiring a professional electrician, it is really a lot safer and even more practical to perform this as a substitute. - 28 Collection Of Complete Circuit Drawing High Quality Free Circuit Diagram Year 2 Circuit Diagram Bbc Bbc Bitesize Electrical Circuits #4551
You will find explanations why these are typically the most usually questioned electrical wiring questions. Just one, lots of think it truly is simple to try and do, and two, they're the common electrical tasks at your house. But then you definately must not set your basic safety in danger with your intention to economize. The stakes could even be a lot higher if you try and cut costs and do an electrical wiring occupation with no adequate expertise or working experience.
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