Disturbed needs in breast cancer. Postoperative period for breast cancer

Historical sketch.

The problem of breast tumors is as ancient as the entire history of medicine. Women's attitude towards the mammary gland as an attribute of femininity carries her through all the years. This feeling determines her consent to see a doctor, her readiness to undergo the surgical treatment he recommends, up to complete removal of the breast, or, conversely, her refusal of any type of treatment.

Breast cancer has been encountered since time immemorial; preserved relics, ancient bones, and paleontological remains indicate that cancer is widespread and affects all living things.

The earliest document related to the history of medicine is the ancient surgical papyrus of Edwin Slifa, dating back to the times of the Egyptian pyramids (2.5 - 3 thousand years BC). The name of the author is reliably known, the text is attributed to the doctor of the ancient world, Imhotep. The papyrus describes 8 cases of breast cancer. Tumors are divided into cold (convex) with swelling of the mammary gland and inflammatory, most likely abscesses. For the treatment of the latter, coagulation is recommended. If a cold tumor (cancer) was detected, no treatment was recommended.

The ancient Greek historian Herodotus (500 BC), 100 years before Hippocrates, tells a story about Princess Atossa, who suffered from a breast tumor. She turned to the famous physician Democedes (525 BC) for help only when the tumor reached a large size and began to bother her. Out of false modesty, the princess did not complain while the tumor was small. This case shows the attitude of a woman to her mammary glands in that very long period of history. The type of treatment is not specified, but the princess was cured.

The famous physician Hippocrates (400 BC) points out that it is better not to treat “deeply located” tumors, because it can hasten the patient's death, and refusal of treatment can prolong life.

The famous physician Galen (131 - 200), perhaps the first to propose surgical treatment of breast cancer while preserving the pectoralis major muscle. He also legitimized the term “cancer” by describing a tumor that looked like a crab. Galen was an adherent of the “humoral” theory of cancer, caused, in his opinion, by “black bile” - a theory that dominated medicine for a whole millennium.

The first surgeon who began to remove not only the mammary gland, but also the axillary lymph nodes for cancer, was Severinus (1580-1656)

In the 19th century principles of breast cancer treatment were formed. In 1882, Halsted, and in 1894, independently of him, Meyer, used the radical mastectomy method in clinical practice, which became a classic method and is currently used.

Later, by studying the pathways of lymphatic drainage, they began to offer extended operations with the removal of axillary, subclavian and parasternal lymph nodes.

These were very mutilating operations, and the results were not satisfactory.

In recent years, extended mastectomies have been abandoned because... Additional treatment methods have appeared in the arsenal of doctors: radiation, chemotherapy, and hormone therapy.

In the last decade, organ-saving operations have been performed in combination with modern treatment methods. The result of this treatment was a significant increase in life expectancy and a decrease in the number of complications and disability.

Anatomy and physiology of the breast.

In their development, the mammary glands are a homologue of the sweat and sebaceous glands, they are formed in the ectoderm and in the first stages of embryonic development they do not differ in men and women.

Sizes M.F. very diverse. On average, the transverse size of M.J. 10-12 cm, longitudinal 10 cm, thickness from 4 to 6 cm. Right M.F. slightly larger than the left in right-handed people. The weight of one gland in girls is 150 - 400 g, in nursing women - 500 - 800 g.

The body of the M.J., or the glandular tissue itself, is embedded in fatty tissue, which is a direct continuation of the subcutaneous fatty layer of neighboring areas. The supporting and strengthening apparatus of the breast is the superficial thoracic fascia, which is attached along the entire length of the clavicle; going down, it is divided into 2 leaves, which cover the gland and form a capsule.

Between the deep layer of fascia and the aponeurosis of the pectoralis major muscle there is a retromammary space filled with loose fatty tissue. This creates a condition for significant mobility of the gland and determines the course of pathological processes.

M.Zh. It is customary to divide into 4 quadrants: upper-outer and lower-outer, upper-inner and lower-inner. M.Zh. consists of 15-20 alveolar tubular glands (lobules), surrounded by loose connective tissue with a small amount of fatty tissue. Each lobe has its own excretory duct with a diameter of 1 to 2 mm with an opening on the nipple of 0.2 to 0.3 mm. The excretory duct near the external opening expands spindle-shaped, forming the milk sinus. Deep in the tissue, the ducts branch, moving to the so-called alveolar ducts. On average, there are from 7 to 30 milk ducts on the surface of the nipple.

Arterial blood supply to M.Zh. receives from 3 branches, all of them anastomose with each other and surround the glandular lobules and ducts with an arterial network. Venous vessels follow the paths of the arterial vessels and flow into the axillary, subclavian, internal mammary and superior vena cava.

Given the venous outflow, cancer emboli penetrate the lungs, pelvic bones and spine.

The lymphatic network consists of superficial and deep plexuses of vessels. The main directions of lymph outflow are the axillary and subclavian lymph nodes. From the central and medial parts of the gland, the lymphatic vessels go deeper, accompanying the branches of the internal thoracic artery and vein, and go to the posterior sternal mediastinal lymph nodes. From the lower internal section of M.Zh. the lymphatic pathways are directed to the epigastrum and anastomose with the lymphatic pathways of the pleura of the subdiaphragmatic space and the liver. There are many anastomoses between the superficial and deep lymphatic networks, and there are also many between the mammary glands.

Starting from 10-12 years of age, the growth of the ducts and surrounding stroma increases in girls. At the age of 13-15 years, the development of the final glandular elements of the alveoli begins. By the age of 16-18 M.Zh. reach normal size. Maximum development occurs between the ages of 25-28 and 33-40 years. During this period, there is a lobulated, alveolar-tubular gland with a well-developed and clearly distinguishable supporting stroma.

At the age of 45-55 lei, involution of the glandular elements and stroma of the breast occurs. In women 60-80 years old, the structure of the mammary gland is characterized by a predominance of subcutaneous fatty tissue, and the gland’s own tissue has the appearance of narrow, coarse fibrous layers.

Development and functioning of M.Zh. depends on neurohumoral regulations, the influence of hormones of the sex glands, adrenal glands and pituitary gland. Regulation of various endocrine functions and metabolic processes is carried out by the cerebral cortex through the diencephalic zone of the hypothalamus.

MASTOPATHY

This disease has other names: Reclus disease, Shimelbusch disease, cystic disease, fibroadenomatosis, sclerosing adenomatosis, etc. Dishormonal hyperplasia in the mammary gland develops under the influence of many factors: impaired childbirth, ovarian-menstrual function, endocrine disorders, social and everyday conflicts (stress) , sexual disorders, liver dysfunction.

Mastopathy is characterized by the proliferation of connective tissue in the form of whitish strands, in which gray-pink areas and cysts with clear liquid are noted.

A number of features should be noted in the etiology of this disease. Firstly, it is important to take into account social and living characteristics. So in 1.5 more often tumors of M.Zh. found in cities than in rural areas. Persons with higher education are 1.7 times more likely than unskilled workers. Mastopathy occurs with frequent negative stress. Conflict is the main cause of strong emotions. Therefore, it is important to identify its sources. These sources can be divided into several groups:

1. Dissatisfaction with marital status.

2. Domestic conflicts.

3. Conflict situations at work.

4. Mental stress.

5. Adverse sexual factors.

If these factors are not resolved, malignancy is possible.

Secondly, reproductive dysfunction. This function is closely related to complex rhythmic processes in the nervous and endocrine systems.

The risk group includes people with early onset of menstruation and late menopause, as well as people who experience anovulatory cycles during the reproductive period. To reduce the risk, especially in youth, it is recommended to increase physical activity, play sports, and dance. Thirdly, these are diseases of the genital organs. First of all, these are inflammatory diseases of the appendages and uterus. Fourthly, these are sexual factors. When discussing sexual problems, it is important to find out the regularity and emotionality (dissatisfaction, oppression, depression) of sexual life. If a significant role of sexual factors in the occurrence and development of mastopathy is established, the patient must be treated together with a sex therapist or psychotherapist. Fifthly, a violation of the inactivating ability of the liver plays a certain role. Treatment of hepatitis and cholecystitis leads to the elimination of mastopathy. Patients with somatic pathology that provokes mastopathy should undergo treatment under the supervision of a mammologist and therapist.

You should pay attention to external signs of endocrine imbalance: constitution (asthenic unfavorable), signs of hypoestrogenism (male type of hair growth, hirsutism, hypoplasia of the external genitalia), obesity after 45 years, as well as dysfunction of the thyroid gland.

People who have relatives with mastopathy need to know that only a predisposition to tumors is inherited, and not a symptom. The realization of a predisposition is possible under unfavorable conditions. Eliminating the causes and changing lifestyle prevents the development of the disease.

The nurse should actively identify women with mastopathy, carry out preventive measures, conversations, recommend them examination, form them into risk groups, monitor their health and teach them self-examination techniques.

The disease manifests itself in two forms: diffuse and nodular.

With mastopathy, pain in the gland is noted in the middle of the menstrual cycle and before menstruation. Patients complain of thickening of the gland and sometimes discharge from the nipple. The pain is characterized as stabbing, shooting, sharp, radiating to the back and neck.

Upon palpation, compactions of a lobular nature with an uneven surface, heaviness of the tissue, and moderate pain are determined. After menstruation, with diffuse mastopathy, the gland is evenly compacted, heavy, the pain may be insignificant. In the nodular form, painless single or multiple foci of compaction are determined. They are not fused to the skin, nipple, surrounding tissues, are mobile, and are not palpable in the supine position (Koenig's sign is negative). No enlarged lymph nodes are observed.

Fibroadenoma. The age of the patients is young, from 15 to 35 years. After 40, malignancy is possible. The tumor is usually solitary. The size of the tumor varies. It has a round shape, clear contours, is painless on palpation, and has a positive Koenig sign.

Leaf-shaped. This tumor has a layered structure, is clearly demarcated from the surrounding tissues, quickly increases in size, and does not have a capsule. It most often becomes malignant and then metastasizes to the bones, lungs and other organs.

A peculiarity in the clinic is exhaustion, cyanosis of the skin in the projection of the tumor.

DIAGNOSTICS.

Palpation examination by a mammologist.
In accordance with age and recommendations of the mammologist, non-contrast mammography or ultrasound of the breast.
Needle biopsy.

Diffuse forms are treated conservatively. Patients should be referred to a specialist, undergo a full examination, after which adequate treatment is prescribed. Nursing staff can recommend proper nutrition and general strengthening activities.

Patients are advised to reduce their weight to normal. Reduce the consumption of animal fats to 30% in calorie content (butter no more than 75 grams per day). It is advisable to strictly limit the use of pickled, smoked and dried foods, fatty meats and whole milk. And eating eggs favorably improves intestinal flora and reduces the possibility of developing a tumor. There is evidence that if coffee, tea, chocolate and tonic drinks are excluded from the diet, after 2-6 months. Pathological changes of a fibrocystic nature disappear.

It is recommended to include liver, fish, vegetables especially with dark green leaves, tomatoes, carrots, sweet potatoes and corn in the diet. There is also a beneficial effect when consuming fruits, especially citrus fruits, vegetables rich in carotene, the cabbage family, and whole grain products. To strengthen the body's defense mechanisms and prevent the occurrence of tumors, it is necessary to introduce vitamins into the diet. The main antitumor vitamins are A, C, E.

Among the methods of surgical intervention, sectoral resection of the mammary gland is used.

The mammary gland is an attribute of femininity, therefore any surgical intervention on it is a severe mental trauma for a woman. However, for tumors, especially malignant ones, surgery is the only radical method of treatment, which is carried out in combination with radiation, chemical, hormonal and symptomatic therapy.

A woman should know that all people are individual and their tumor process proceeds differently depending on the type of tumor, its stage, hormonal levels, age, and concomitant diseases. Therefore, you cannot compare yourself with your roommate. For each person, treatment is selected individually, taking into account the characteristics of his body.

In the preoperative period, the nurse is obliged not only to ensure the successful completion of the operation (somatic, medicinal preparation), but also to morally support the patient, prepare her for an adequate perception of a cosmetic defect - absence of a breast, the presence of a scar, swelling of the arm. In your conversations, it is necessary to familiarize the woman in advance with the nursing care plan in the first days after the operation, as well as give recommendations for the rehabilitation of the patient’s condition after discharge from the hospital in order to return her to a full life as soon as possible.

Care in the early postoperative period

The operation ends with the introduction of drainage into the wound to drain the contents and prevent the aseptic dressing secured with an adhesive plaster from getting wet. The free end of the tube is connected to a container ("accordion" or "pear") from which air has been removed to ensure vacuum drainage according to Redon. The nurse provides observation and care in accordance with the following algorithm.

Algorithm for the care of active vacuum drainage according to Redon.

Wear gloves.
Pinch the drainage tube above the container.
Place a gauze pad or ball under the junction of the tube and the container.
Using rotating movements, carefully remove the container with liquid from the tube.
Pour the contents of the container into a volumetric flask.
By compression, release the air from the container above the vessel with the disinfectant solution and, in this form, attach the container to the end of the drainage tube.
Remove the clamp.
Place the volumetric flask with its contents in a disinfectant solution and process it in accordance with OST.
Remove gloves and place in disinfectant solution.
Make a note on the patient's nursing observation sheet or in the NIB about the amount and nature of discharge from the wound.

Note. The container is emptied as it is filled.

It is necessary to provide care for the arm on the affected side, as it swells due to the accumulation of lymphatic fluid due to the removal of lymph nodes. Therefore, in the first days after surgery, the arm should be tightly bandaged or suspended in a supporting bandage and ensure an elevated position. Exercise therapy for the sore arm begins on the first day after surgery.

To combat pain in the area of the postoperative wound, the nurse administers narcotic and non-narcotic analgesics as prescribed by the doctor.

Care in the late postoperative period

Care in the late postoperative period includes: postoperative scar care, hand care on the affected side, general recommendations, breast cancer prevention measures.

Postoperative scar care. The next day after removing the sutures, make sure that the patient takes a warm (37-38 °C) shower or bath. This procedure should be repeated daily for 5-10 days.

During the water procedure, the skin around the scar should be washed with a gauze napkin, and then wiped with a gauze napkin using blotting movements. After drying, the seam line (“black crusts”) is treated with alcohol or vodka, then with brilliant green. The treatment is repeated until a smooth scar is formed.

Every day, lubricate the skin around the scar with baby cream or pasteurized vegetable oil and apply gauze bandages until the “crusts” fall off. Manufacturing technique: roll out a thin layer of cotton wool, apply a wide bandage on top of it and cut out a bandage of the required length.

Note. A bandage is applied to the surface of the wound.

Specially made prostheses can be used a month after the wound has completely healed.

Caring for the hand on the operated side. Due to the technical features of the operation (removal of lymph nodes, part or all of the pectoral muscle), pain in the arm, swelling, and mobility are impaired, so the patient needs to do therapeutic exercises for 6 months. after surgery. The main task of exercise therapy is to restore the range of motion to a normal level after 1.5 months. after surgery and minimize swelling of the upper limb.

sunbathing and being naked in the sun;
take physiotherapeutic procedures on the area of the postoperative wound; including the armpit;
take vitamin B12, folic acid;
take biogenic stimulants (aloe, vitreous, etc.);
take hormonal medications without your doctor's knowledge.

For the first 2 years after surgery, you can only rest in a climate zone similar to your area of residence.
Follow a diet rich in vitamins B2, B6, C and complete proteins (cottage cheese, fish, chicken, meat). Limit sweets, flour products, animal fats - do not gain weight!

Nursing process

breast cancer.

Epidemiology

· The incidence of breast cancer in Russia, as in most countries of Europe and North America, is growing.
· In the structure of cancer incidence in Russia, cancer of this localization has held first place since 1985.

Worldwide, in 2000, more than 796,000 cases of breast cancer were newly diagnosed: - in the United States of America - more than 183,000; – in the UK – about 26,000.

In 2001, 45,257 patients with malignant neoplasms of the mammary glands were identified in Russia.
·Over the past 10 years, the annual increase in incidence is 5.8%, amounting to a total of 31.2%.
In 17.8% of cases, detection is associated with preventive examinations.

In Russia, 60.0% of breast cancer was diagnosed in stages 1-11, in 26.1% - in stage 111, and in 12.5% - in stage 1V of the disease.

The highest incidence rates and growth rates were observed in the age groups 60-64 years (136.5 per 100,000 population) and 65-69 years (133.2 per 100,000 population).
· At younger ages: 20-24, 25-29, 30–34, 35-39 – incidence rates have stabilized, amounting to: 0.59 and 0.67; 3.42 and 3.9; 13.12 and 13.5; 31.59 and 32.5 per 100,000 population, respectively.
· The highest standardized incidence rates were registered in the Khabarovsk Territory - 49.7, St. Petersburg - 48.3 and Moscow - 46.4.
· Malignant neoplasms of the mammary glands have the largest share in the mortality structure - 16.5%.
· In 2000, approximately 312,000 patients died from breast cancer worldwide.
· Every year in the United States, 2,000–3,000 women die from breast cancer.
· In Russia, 13,000 patients died from breast cancer in 2000.
· The highest age-specific mortality rate occurs in those aged 75 and over – 86.2 and in those aged 70-74 – 75.8 per 100,000 population.
· The highest mortality rates in 2001 were characteristic of St. Petersburg - 23.0, Moscow - 22.6 and the Kamchatka region - 22.8.
· More than 66% of women with breast cancer did not have the most important risk factors for the disease.
· Of the 367,632 breast cancer patients under observation in Russia in 2001, 199,408 women were observed for 5 or more years.

Average survival rate for this pathology in Russia.

Risk factors

About 66% of women with breast cancer are unaware of the existence of risk factors.

Factors increasing risk:

The ratio of sick women to men is 135:1.

Age.

– the age group 55-65 years old has the highest risk of developing breast cancer,

– only about 10% of patients are under 30 years of age.

Menstrual status:

Early menarche (before 13 years) – the risk increases by 2-2.5 times; – late menopause (after 55 years);

– long period of menopause (78% of patients have various menopausal disorders.

State of the reproductive sphere:

– late first birth (the risk increases by 40% in the group where the first pregnancy and childbirth were after the age of 25);

– a history of abortion, especially before the first birth.

Hormonal factors:

– use of hormonal drugs during pregnancy, especially estrogen ones;

– the use of hormone replacement therapy in the postmenopausal period is a controversial risk factor

hormone replacement therapy slightly increases the risk of developing breast cancer only during its use (approximately 2.1 times);
upon completion of its use, the risk decreases;

Duration of use with minimal risk – 2 years; – oral contraceptives:

the risk is minimal;
a slight increase in the percentage of women with breast cancer is observed with continuous use of contraceptives for 6 to 10 years.

Mastopathy:

– the risk of increased morbidity is minimal with low proliferative activity; – increases more than 3 times with atypical epithelial proliferation.

Anamnestic data on other oncological pathologies:

– 2 times higher risk of developing breast cancer among patients suffering from endometrial or ovarian carcinoma;

– an exposure dose of 100 rad increases the risk of breast cancer by 3 times; -radiation therapy used in the treatment of Hodgin's lymphomas increases the risk of breast cancer, especially in young patients, with a tendency towards bilateral lesions.

· Alcohol:

– drinking alcohol in a dose of 50 ml daily increases the risk of developing breast cancer by 1.4 – 1.7 times.

Genetic factor:
· An assumption was made about the hereditary nature of breast cancer after studying the clinical features of the occurrence of breast cancer:

– the average age of hereditary forms of cancer is 44 years, which is approximately 10-16 years higher than in the population;

The cumulative risk of second breast cancer over a 20-year follow-up period for the hereditary form reaches 46%;

– hereditary breast cancer can be combined with other types of tumors (integral specific hereditary breast cancer syndrome).

· The genetic substrate has now been identified – the BRCA-1 and BACA-2 genes.

– BRCA-1 is a cytosomal dominant gene localized on chromosome 17:

Its expression increases the overall risk to 85%, with 33-50% under the age of 50 years and 56-87% under the age of 70 years. The overall risk in the population at the corresponding ages is 2% and 7%, respectively;

increases the risk of cancer by 28-44%

– BCRA-2 is localized on chromosome 13:

· its expression increases the risk to 85%;
· expression of this gene is a risk factor for the development of highly differentiated

breast cancer with low mitotic index; – genetically determined syndromes:

· breast cancer + brain tumor;
· breast cancer + sarcoma;
breast cancer + lung cancer + laryngeal cancer + leukemia;

SBLA syndrome + sarcoma + breast cancer + leukemia + adrenal cortex carcinoma;

GOWDEN disease + thyroid cancer + adenomatous polyp + colon cancer + breast cancer;

BLOOM disease + breast cancer;
ataxia-teriangiectasia + breast cancer.

– examination by a specialist starting from the age of 20;

Annual mammography from the age of 25-35 years;

Use of ultrasound CT, pelvic Dopplerography and examination for CA 125,

– the use of prophylactic mastectomy can be recommended subject to certain principles:

This is not an emergency event;
possibly at menopausal age or in a nursing woman with a child;
Prophylactic mastectomy reduces, but does not completely eliminate, the risk of developing breast cancer. The most significant studies:

Potential Risk Factors

Diet:

– between a low-calorie diet and a low risk of developing breast cancer.

Obesity:

– is more of a risk factor in the group of postmenopausal patients.

· Hypothyroidism.
· 3 liver diseases.
· Hypertonic disease.

Diabetes.

Factors that reduce the risk of morbidity breast cancer

· Early first birth: the birth of the first child before the age of 18 years.
· Active circulation:

37% had a reduced risk of breast cancer with regular examinations

from specialists.

Lactation:

– breastfeeding at a young age reduces the risk of developing breast cancer

glands during menopause.

Breast cancer is the most common form of malignant neoplasm. It should be noted that the incidence of breast cancer and associated mortality in Russia has increased significantly over the past 20 years. Unlike most tumors of other organs, malignant breast tumors belong to the group of oncological diseases, in the timely detection of which the woman herself often plays a decisive role. Countries, regions or social groups of the population with a high level of sanitary culture, receiving modern qualified information in the field of oncology, are characterized by an incomparably lower proportion of advanced cancer cases in the overall morbidity structure and significantly higher survival rates of treated patients.

Individual and population risk factors contributing to the development of breast cancer:

female gender and age over 50 years;
personal or family history of breast cancer;
atypical proliferative diseases of the mammary gland;
exposure to ionizing radiation;
long childbearing period (early onset and late cessation of menstruation);
absence of pregnancy and breastfeeding;
late first birth (after 35 years);
hormone replacement therapy with estrogen in the postmenopausal period;
excess body weight;
alcohol abuse;
food high in animal fats.

Breast cancer is a tumor growing from the epithelium of the mammary gland and arising in its ducts or lobules. Depending on the growth characteristics, they are distinguished nodular, diffuse forms And Paget's cancer.

Nodular cancer in the early stage it is a painless, mobile, dense node with relatively clear boundaries (Fig. 11). Subsequently, his mobility becomes limited. In the late period of the disease, the skin, areola, nipple, and pectoral muscles are involved in the pathological process. Skin damage is manifested by wrinkles over the tumor, retraction (umbilication symptom), lymphostasis (orange peel symptom), ulceration, and tumor growth.

At diffuse cancer The mammary gland increases in volume and becomes denser, tumor nodules are not detected in it, the skin has the appearance of an orange peel, the nipple is retracted and fixed. Sometimes this form of cancer occurs with hyperemia and increased temperature of the skin of the breast (reminiscent of erysipelas or mastitis).

Rice. eleven.

It is characterized by an initial lesion of the nipple, which thickens with the appearance of dry and wet crusts (Fig. 12). The latter fall off and reveal a grainy and moist surface. Gradually, the nipple thickens and ulcerates, the process spreads to the areola, skin and deeper into it.

In all forms of breast cancer, the axillary, subclavian and supraclavicular lymph nodes are affected; they are painless and have a dense consistency.

At the beginning of the disease, there may be no complaints. As the tumor grows, pain occurs in the chest, and when it metastasizes to the lungs and pleura, cough and shortness of breath appear.

The nature of the disease and its prognosis depend on the size of the primary tumor, the type of skin lesions of the breast, chest, lymph nodes, and the presence or absence of distant metastases.

Stages of breast cancer:

Stage 0 - tumor in situ without invasive growth, damage to lymph nodes and the presence of distant metastases;
Stage I - the presence of a tumor no more than 2 cm in diameter in the absence of damage to the lymph nodes and distant metastases;
Stage II - the presence of a tumor measuring from 2 to 5 cm in diameter without involvement of lymph nodes in the pathological process and without distant metastases;

Rice. 12.

Stage III - the presence of a tumor with a diameter of 5 to 10 cm, damage to the lymph nodes in the absence of distant metastases;
Stage IV - the presence of a tumor of any size in combination with (or without) involvement of the lymph nodes and distant metastases.

Diagnostics. An examination to detect breast cancer at an early stage includes examination of the breast, palpation in horizontal and vertical positions, palpation of the cervical, supraclavicular, subclavian and axillary lymph nodes, clinical examination by a specialist mammologist, and mammography. Women should be taught breast self-examination techniques (Figure 13).

Clinical studies: general and biochemical blood tests, determination of the level of tumor markers, fluorography, radioisotope study of skeletal bones, ultrasound of the liver. If there is a palpable formation in the mammary gland, a puncture, targeted or open (surgical) biopsy is performed, followed by a cytological examination of the biopsy.

The American Cancer Society recommends monthly self-examination for all women over 20 years of age, clinical examination by a breast specialist every 3 years from age 20 to 40, and annual mammography after age 40.

Principles of treatment. Currently underway complex therapy breast cancer: surgery(segmental, total, radical mastectomy), radiation, chemo-, hormone- And immunotherapy. The work of a nurse in an oncology department and a hospice is built taking into account the principles of ethics and deontology, requires organization, special attention and sensitivity towards patients. A woman who has undergone surgery for breast cancer suffers double mental trauma: firstly, because she has cancer, and secondly, because as a result of the operation her appearance changes. She needs psychological support from medical workers, relatives and friends.

There is often a need symptomatic treatment complications of radical therapy (if there is lymphatic swelling of the arm, limited mobility in the shoulder joint, gross scar changes in the skin and soft tissues, erysipelas on the side of the operation), as well as chronic pain syndrome, heart and pulmonary failure, infectious complications, anemia, etc.

Rice. 13. Techniques for breast self-examination

Visible changes in the mammary gland are better identified:

at certain positions of the body and hands:
with arms hanging along the body (a);
with hands raised and behind the head (b);
when lifting the mammary gland up with your fingertips (c);
when pressing on the peripapillary area (G)

When turning the body to the right and left in the above positions ( a-d) the following signs are visible:

changes in the contours (recession, bulging, sagging) and size of the glands;
enlargement or reduction of one of the glands;
Tightness of the glands to the side or upward;
changes in the contractility of the gland, the appearance of its “fixity”;
change in skin color, the appearance of swelling, crusts, fistulas, compactions, nodes over any part of the gland and near it;
the appearance of discharge from the nipple when pressing on the isola. Self-examination (palpation) of the outer sectors of the mammary glands is carried out by placing the hand behind the head on the side of the examined mammary gland, with the pads of 2-4 fingers from bottom to top in the direction from the nipple to the armpit with concentric and radial movements (f, g), be sure to include the supraclavicular, subclavian and axillary areas (e). In healthy people, lymph nodes cannot be felt in these areas. Then, with the pads of 2-4 fingers, the internal (along the sternum) sectors of the mammary gland are felt. After this, the opposite gland is examined using similar techniques.

Nursing assistance. In addition to the usual (routine) activities related to the collection of anamnestic data (determining the presence of risk factors, etc.), identifying problems and needs, clinical examination, physical and psychological support for the patient, nursing care for breast cancer includes a number of other components.

Components of nursing care:

educational work - informing the patient about the disease, methods of its diagnosis, prevention and treatment in an accessible form;
training women in self-examination of mammary glands;
regular treatment of the wound (ulcer) at the site of the disintegrating tumor: application of aseptic dressings, topical use of metronidazole powder to eliminate odors;
caring for the wound and drainage system after surgery, teaching the patient how to carry out these activities;
prevention of infectious complications in the wound area, infections of the respiratory, urinary and other systems;
prevention and treatment of lymphedema using hand massage, training in self-massage techniques, etc.;
relief of chronic pain syndrome (internal and parenteral use of analgesics);
treatment of depression caused by loss of external attractiveness, financial independence, family troubles (conversations with a nurse, psychotherapist, relatives, priest);
informing about the possibility of performing plastic surgery, wearing a special corset;
dynamic monitoring of the patient’s condition and compliance with doctor’s orders;
encouragement of reasonable physical activity, assistance in performing physical therapy exercises.

Historical sketch.

Breast cancer has been encountered since time immemorial; preserved relics, ancient bones, and paleontological remains indicate that cancer is widespread and affects all living things.

The famous physician Hippocrates (400 BC) points out that it is better not to treat “deeply located” tumors, because it can hasten the patient's death, and refusal of treatment can prolong life.

The first surgeon who began to remove not only the mammary gland, but also the axillary lymph nodes for cancer, was Severinus (1580-1656)

Later, by studying the pathways of lymphatic drainage, they began to offer extended operations with the removal of axillary, subclavian and parasternal lymph nodes.

These were very mutilating operations, and the results were not satisfactory.

In recent years, extended mastectomies have been abandoned because... Additional treatment methods have appeared in the arsenal of doctors: radiation, chemotherapy, and hormone therapy.

Anatomy and physiology of the breast.

Given the venous outflow, cancer emboli penetrate the lungs, pelvic bones and spine.

MASTOPATHY

Mastopathy is characterized by the proliferation of connective tissue in the form of whitish strands, in which gray-pink areas and cysts with clear liquid are noted.

1. Dissatisfaction with marital status.

2. Domestic conflicts.

3. Conflict situations at work.

4. Mental stress.

5. Adverse sexual factors.

If these factors are not resolved, malignancy is possible.

Secondly, reproductive dysfunction. This function is closely related to complex rhythmic processes in the nervous and endocrine systems.

The disease manifests itself in two forms: diffuse and nodular.

A peculiarity in the clinic is exhaustion, cyanosis of the skin in the projection of the tumor.

DIAGNOSTICS.

Palpation examination by a mammologist.
In accordance with age and recommendations of the mammologist, non-contrast mammography or ultrasound of the breast.
Needle biopsy.

Among the methods of surgical intervention, sectoral resection of the mammary gland is used.

MAMMARY CANCER

The incidence of breast cancer is 15.9 patients per 100,000 women. Among oncological diseases it ranks 4th after cancer of the stomach, uterus, and skin. The incidence ratio among men and women is 1: 100, and out of 14 women, 1 is sick.

The most affected age is 50-60 years and older. Risk factors include:

1.Incidence of cancer in the past.

2. Hereditary predisposition: only 5% distinguish between “family” and “hereditary” (mother, grandmother, sister are sick).

3. Absence of childbirth (nuns)

4.Early appearance of menstruation before 12 years of age; the later menstruation occurs, the more favorable the prognosis.

5.Dysplasia (fibroadenomatosis).

6.Cancer of the uterine body.

7. Living in a developed country is a stress factor (Japanese women)

8. Radiation effect. Radiation damage especially to girls aged 10 to 19 years. Moreover, the tumor appears 15–30 years after irradiation. Repeated treatment or X-ray diagnostics of more than 100 images over several years, therefore they switch to other types of examination.

9. The use of hormonal drugs as replacement therapy during menopause.

Protective (positive) factors include:

1. Long-term breastfeeding.

2. Early removal of the ovaries (decreased estrogenic activity, excessive synthesis of sex hormones).

3.Multiple pregnancies (childbirth).

There are diffuse and nodular forms of R.M.J. Nodular forms are more common and are characterized by the following clinical manifestations:

1. Painless formation, dense consistency, with uneven contours and surface.

2. Dermatological manifestations - erosions, eczema, Paget's disease, "lemon" crust, "umbilification" - the skin over the tumor is wrinkled, retracted.

3. Discharges – serous or bloody.

4. Asymmetry - the nipple is deviated to the side, retracted and deformed (Pribram's symptom).

5. Fixation of the breast to the chest (growth into the pectoralis major muscle) – Payr’s symptom.

6. Coloring – dyspigmentation, as during pregnancy

7. Generalization – metastasis to regional lymph nodes, bones, liver, lungs, brain.

These manifestations of a malignant tumor are considered advanced symptoms. In the early stages, the tumor is dense, does not bother the patient in any way, often is an accidental discovery, or an attentive attitude to one’s health. Such patients regularly undergo preventive examinations of the mammary glands.

Diffuse forms of breast cancer include:

1. Infiltrative.

2.Lymphatic (edematous).

3. Ulcerative.

4. Armor cancer.

5.Erysipelas.

6. Mastitis-like.

7. Paget's cancer.

These forms most often affect young women. The infiltrative-edematous form is observed during pregnancy or lactation. The pain appears late. The tumor quickly increases in size. There are no clear boundaries. Metastases appear early in regional lymph nodes.

Mastitis-like cancer is difficult to distinguish from ordinary mastitis, so if mastitis occurs in a non-lactating woman or an elderly woman, you should be wary of cancer and consult a specialist.

Erysipelas-like cancer can easily be mistaken for erysipelas, as it has several characteristic signs: infiltration, hyperemia of the skin with uneven, tongue-shaped edges, and local hyperthermia. It is often impossible to determine the tumor node by palpation. Characteristic is cancerous lymphangitis in the form of hyperemic stripes, located mainly along the intradermal lymphatic pathways.

With armored cancer, the gland decreases in size compared to healthy ones, its mobility is limited, the skin is thickened and resembles a shell.

Paget's cancer. It begins with Paget's disease, a kind of eczema of the nipple, which turns into cancer after about 2 years. Paget's disease has 3 stages: eczema, ulcer, cancer. Initially, redness and thickening of the skin in the nipple area appears. Itching appears, weeping is replaced by crusts, scales and superficial bleeding ulcers. The lesion covers the areola, the nipple is deformed, destroyed, and a tumor node is identified in the gland. This form metastasizes quite late.

DIAGNOSTICS.

1. Anamnesis is important.

2. Examination of the mammary glands. (see self-examination)

A) There must be sufficient lighting.

B) It is carried out in two positions - standing and lying down. Standing - arms along the body, standing - hands behind the head. This way the shape of the breast is more clearly defined.

C) Note the position of the nipple: deviated from the center (usually towards the tumor), flattened, retracted, ulcerated nipple and areola.

D) Deformation of the areola - shortening of one of its radii.

D) Varying degrees of skin retraction.

E) More developed subcutaneous vascular network, swelling of the skin, a symptom of “lemon peel”.

3. Palpation - in a vertical and horizontal position, the following is determined:

Size, border, growth form, consistency and nature of the surface of the tumor, its relationship with surrounding tissues, displacement in relation to them.

Palpate with the pads of the 2nd, 3rd, and 4th fingers, placed flat on the palpable breast - superficial palpation, and then deep. Koenig's symptom is determined - the tumor does not disappear upon palpation while lying down and standing, a "platform" symptom. Then the axillary, subclavian, supraclavicular and cervical lymph nodes are carefully palpated. Sometimes this is the primary sign of cancer; the tumor in the mammary gland is not palpable.

4. X-ray studies. Mammography (non-contrast) or xerography (electroradiography) is a study based on the use of electrostatic charge. Ductography is the introduction of a contrast agent through the ducts.

5. Thermography - “hot” and “cold” spots - research in infrared light (many false diagnoses). Thermal spray film.

7. Biopsy:

A) puncture – performed with a thin needle on the day the special treatment begins.

B) trephine - a biopsy is performed with a thick needle.

B) excisional – excision of a node with healthy tissue.

SELF-EXAMINATION.

80% of cases of breast cancer are discovered by patients themselves by chance. To identify early forms of breast cancer, a special place is given to nurses. So the nurse can conduct preventive examinations and conduct propaganda among the population. With certain knowledge, women are more

They take responsibility for their health. They do not develop cancerophobia,

and even in the presence of cancer symptoms, such patients are more willing to contact a doctor than others.

To promote and educate the population, it is most effective to use:

1. articles in newspapers and magazines

2. showing films and giving lectures in industries where there are many working women.

3. Distribution of popular science brochures.

4. Conducting lectures in lecture halls.

The nurse's role is especially important in cases where women are trained in self-examination but do not perform it because are afraid of being diagnosed with cancer, or believe that this cannot happen to them. Repeated repetition, agitation, propaganda give positive results. The nurse can also examine patients during patronage. Remember! A woman who examines her mammary glands regularly

knows them better than any specialist. She is able to identify a tumor less than 1 cm in size and distinguish a benign tumor from a malignant one.

It is necessary to examine the breast once a month in the first week after mens, because This is the most favorable time to identify compactions. A woman in menopause chooses any day and strictly adheres to it. Remember that the tumor doubles its volume no faster than after 20 days.

Training of women can be carried out individually or in groups of 5 – 20 people

The level of sanitary propaganda and the general cultural level of the population are of a certain importance; it is easier to understand and perform self-examination at the age of 35–50 years, married people with higher and secondary specialized education. Such people consider health to be the highest value in life.

The role of the nurse in identifying and forming risk groups is not unimportant. Screening programs in developed countries have now made it possible to reduce mortality from this disease.

In promoting self-examination, psychological emphasis must be correctly placed. The most correct orientation for women during self-examination is to compare the procedure with other hygienic measures. For example, brushing your teeth, freshening your mouth is the prevention of caries. Taking a bath or shower prevents unpleasant odors, the development of skin diseases, etc.

CANCER PREVENTION

1. “ideal” weight.

2. Taking vitamins. A, E, S. (see mastopathy)

3. Refusal of uncontrolled use of hormones (especially estrogens).

4. Low fat diet. The diet must include sufficient quantities of fresh fruits and vegetables, herbs, and reduce

consumption of animal fats, alcohol, products containing nitrates and nitrites, pickles, products contaminated with mycotoxins, reduce consumption of canned food. It is known that the oxidation products of unsaturated fatty acids are strong mutagens and carcinogens. It has also been proven that mutagens and carcinogens are formed during frying.

Prevention of breast cancer is limited, but with proper implementation of organizational and methodological measures, secondary prevention makes it possible to detect a tumor in the early stages of the disease and prolong the life of patients.

It must always be carried out comprehensively. Treatment depends on the extent of the process, the patient’s age, the morphological structure of the tumor, the state of menstrual and ovarian function, general condition, and concomitant diseases. The leading method is surgical. The following operations are performed: radical mastectomy according to Halsted and Mayer, mastectomy according to Patey, organ-saving operations (sectoral resection + removal of lymph nodes in the armpit), breast amputation, simultaneous mastectomy and replacement plastic surgery (contour mammoplasty). Surgical treatment is combined with chemotherapy. The most commonly used complex is CMF: C - cyclophosphamide, M - methotrexate, F - 5-fluorouracil. Radiation therapy is sometimes used. Lately, hormone therapy (usually tamoxifen) has become more common.

If a pregnant woman is diagnosed with breast cancer, an urgent termination of pregnancy is necessary.

Minimal tumors are curable - 95%, Tumors about 2 cm (stage 1) - 85%, tumors about 5 cm (stage 11) - 70%, with metastasis to other organs, survival rate - 10%.

GYNECOMASTIA.

Gynecomastia has been known since ancient times. The term was introduced in the 5th century by Paul of Aegina. This disease is quite common and is divided into true and false gynecomastia. False gynecomastia is the growth of adipose tissue due to metabolic disorders. True gynecomastia is of two types: diffuse and nodular.

Gynecomastia is a symptom complex that occurs as a result of complex neurohumoral changes.

1. Humoral factors - an increase in female sex hormones, which

synthesized by the gonads and adrenal cortex, or changes in androgen metabolism.

2. Functional or anatomical lesions of the testes

A) testicular tumors.

B) anomalies, imperfect development of the genital organs.

C) trauma and damage to the spermatic cord and testicle (for example, operations for a hernia, dropsy, varicocele).

D) chronic diseases of the testicle and appendages.

D) with long-term use of estrogens (treatment of cancer, prostate adenoma)

3. With long-term treatment with corticosteroids (prednisolone, prednisolone), for burns, polyarthritis and other diseases).

4. Diseases of the thyroid gland (hyperthyroidism).

5. Liver diseases (cirrhosis, hepatitis, metabolic disorders in the body).

6. As a result of sexual metamorphosis in adolescence or old age.

True gynecomastia occurs with an increase and development of the glandular tissue of the mammary glands. In this case, the areola may change, and the nipple may be partially formed according to the female type. Glandular tissue is determined by palpation. This disease most often occurs between the ages of 21 and 45 years.

Juvenile gynecomastia occurs between the ages of 10 and 20 years. On average, 17% of boys (about 14 years old) have small nodules that are painful to palpation. By the age of 17, all phenomena go away on their own. No correction is required. Rarely, the increase may persist for a longer period of time. In this case, you need to consult a doctor for examination.

False gynecomastia - occurs due to metabolic disorders. At the same time, the gland is soft, painless, the size is significantly increased, there is no discharge. Gynecomastia is usually bilateral.

The main task is to identify clear causes of the disease. Regulate metabolic processes. Treatment can be carried out conservatively by introducing hormones (androgens) or surgically with preservation of the nipple or complete removal along with the nipple. Typically, nodular forms of tumors that are not amenable to conservative treatment are treated in this way.

BREAST CANCER.

Breast cancer in men is a very rare disease and accounts for 0.8 - 2.2% in relation to breast cancer in women. The average age of patients is 52-56 years. Hormonal imbalances play a major role in the development of breast cancer in men. Treatment is combined: surgery + hormone therapy, or chemotherapy, or radiation therapy. The prognosis is less favorable than in women.

Control questions

List the symptoms of malignant breast diseases?

What early signs of breast cancer do you know?

What late manifestations of breast cancer do you know?

Caring for the patient after mastectomy.

Possible options for breast prosthetics?

Disturbed needs in breast cancer. Postoperative period for breast cancer

Care in the early postoperative period

Care in the late postoperative period

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