Breast Cancer Case Study

Mrs. Thomas, a 57 year old married lawyer, was found to have a 4 X 6 cm firm, fixed mass in the upper, outer quadrant of the right breast during a routine physical examination, and a stereotactic core biopsy indicated a malignant tumor. Although the surgeon recommended a mastectomy because of the size of the tumor, Mrs. Thomas chose to have a lumpectomy. Now three weeks postoperative, she is scheduled for chemotherapy. Subjective Data

Never had a routine mammogram
Never practiced Breast Self-Examination (BSE)
States she deserves to have breast cancer for being so careless about her health Chose to have a lumpectomy to remove the tumor despite its large size because she believes that her breasts are critical in her relationship with her husband Objective Data

Physical examination:
Right breast: Healed lumpectomy breast incision and right axiliary incision Limited ROM of right arm
Groshong broviac catheter in place on left upper chest
Diagnostic studies
Pathology: Estrogen receptor-positive infiltrating ductal carcinoma; 8 of 12 lymph nodes positive for malignant cells Staging: Stage IIIB carcinoma of the right breast
Clinical course
Lumpectomy performed to remove tumor 3 weeks ago
Chemotherapy with CAF protocol planned – cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), and 5-fluorouracil (5-FU)

1. Why is chemotherapy indicated for Mrs. Thomas? It is indicated for Mrs. Thomas as adjuvant treatment and may help reduce the chance of breast cancer recurrence.

2. Compare the three chemotherapeutic agents planned for Mrs. Thomas with
respect to classification type, cell specificity and common side effects? 1) Cyclophosphamide (Cytoxan)
Alkylating agent
DNA replication
Side effects – low blood counts, hair loss, n&v, loss of fertility, discoloration of the skin or nails 2) Doxorubicin (Adriamycin)
Anthracycline antibiotic
Intercalating DNA
side effects – Pain (med site), n&v, low blood counts, hair loss, mouth sores 3) 5-fluorouracil (5-FU)
Antimetabolite
Irreversible inhibition of thymidylate synthase
Side effects – n&v, low blood counts, mouth sores, diarrhea, poor appetite, discoloration (med site), photophobia, metallic taste in mouth during infusion

3. What can the nurse do to help Mrs. Thomas reduce or manage the common physical effects of the chemotherapy? Nausea & Vomiting – anti-emetic drug, eat and drink slowly, drinking enough fluids Mouth sores (Mucositis) – OTC anesthetics, ice chips or popsicles, gargling Diarrhea – drink plenty of fluids, high-protein foods, cooked vegetables, fresh fruits without the skin Hair loss – wear some kind of head covering (scarf, turban, hat, or wig)

4. What does the finding that Mrs. Thomas’s tumor is estrogen receptor-positive mean? What additional treatment modalities might this suggest? This means that estrogen, but not progesterone, may be supporting the growth and spread of the cancer cells. Your doctor usually will prescribe some form of hormonal therapy at some point in your treatment plan.

5. How could the nurse help Mrs. Thomas cope with her feelings of guilt and maintain a positive relationship with her husband? The nurse could listen to and explore Mrs. Thomas’s feeling of guilt. Inform her about support groups and counseling that are available in her area.

6. What are some possible reasons that Mrs. Thomas did not perform BSE or have mammography performed? Not confident in the technique of BSE
Fear that something may be found
Losing her sexual identity
Anxiety

7. What teaching by the nurse is indicated for Mrs. Thomas regarding follow-up care related to recurrence of the breast cancer? Have a mammogram every 12 months
Have a physical exam by a health care provider every four to six months for five years, then every 12 months Perform a breast self-examination every month
Have regular bone density tests if you have a higher risk of osteoporosis Take medications as prescribed by your doctor
Maintain an active lifestyle and healthy body weight

8. Based on the assessment data presented, what are three appropriate nursing diagnoses?
I. Risk for infection
II. Ineffective coping
III. Disturbed body image

9. What interdisciplinary problems may require assistance from other members of the health care team? Medical & Physical exams
Surgery
Radiation/Chemotherapy
Diagnostic tests
Counseling