**2. Caring for patient in breast cancer diagnosis**

The diagnosis of breast cancer is identified in someone who has breast cancer risk. Most women included in the risk group pay more attention to any changes in their breasts. The following groups are at risk of developing breast cancer [2]:

	- **1.** Li-Fraumeni syndrome increases the risk of developing certain types of cancer, including breast cancer, osteosarcoma, soft tissue sarcoma, and leukemia. Most people with Li-Fraumeni syndrome have inherited a mutation in the TP53 gene, which is normally a tumor suppressor gene.
	- **2.** Ataxia telangiectasia (AT) is caused by a mutation of the ATM gene. This gene is responsible for repairing damaged DNA. Certain families with a high rate of breast cancer have mutations of this gene.
	- **3.** Cowden syndrome is caused by a mutation in the PTEN gene, which is normally a tumor suppressor gene. People with this condition are more likely to develop breast cancer, gastrointestinal cancers, and thyroid cancer.
	- **4.** Peutz-Jeghers syndrome may be related to a mutation of the STK11 (also known as LKB1) gene. This gene appears to normally function as a tumor suppressor gene. Peutz-Jeghers syndrome increases the risk of developing gastrointestinal, breast, ovarian, and testicular cancers.

cancer than women with little or no dense breast tissue. Breast density can only be seen on a mammogram, but dense breasts also make a mammogram harder to read. On a mammogram, fatty tissue looks dark, while dense tissue looks white, like tumors, so it can hide a tumor.

Most women diagnosed with breast cancer are already in a late condition where the breasts have given an unpleasant condition, foul smell, and excessive fluid. The existence of women in the family as wives, mothers, and caregivers of families becomes disrupted, and some

Caring in women with breast cancer requires a variety of understanding of the development, roles and functions of women with breast cancer, and psycho-spiritual and psychosocial needs. The context of understanding conditions under conditions of diagnosis, therapy, and

The diagnosis of breast cancer is identified in someone who has breast cancer risk. Most women included in the risk group pay more attention to any changes in their breasts. The

**a.** Personal history of breast cancer. Women who had breast cancer in the past have a higher risk of developing breast cancer again. Breast cancer can develop in the same breast as the

**b.** Family history of breast and other cancers. The greatest risk in family history of breast cancer is from mother, sister, or daughter who had breast cancer, especially if they were

**c.** Certain genetic conditions. The following rare inherited genetic conditions are linked with

**1.** Li-Fraumeni syndrome increases the risk of developing certain types of cancer, including breast cancer, osteosarcoma, soft tissue sarcoma, and leukemia. Most people with Li-Fraumeni syndrome have inherited a mutation in the TP53 gene, which is normally

**2.** Ataxia telangiectasia (AT) is caused by a mutation of the ATM gene. This gene is responsible for repairing damaged DNA. Certain families with a high rate of breast can-

**3.** Cowden syndrome is caused by a mutation in the PTEN gene, which is normally a tumor suppressor gene. People with this condition are more likely to develop breast

**4.** Peutz-Jeghers syndrome may be related to a mutation of the STK11 (also known as LKB1) gene. This gene appears to normally function as a tumor suppressor gene. Peutz-Jeghers syndrome increases the risk of developing gastrointestinal, breast, ovar-

**d.** Dense breast. Dense breasts have more connective tissue, glands, and milk ducts than fatty tissue. Breast density is an inherited trait. Some studies show that women with dense breast tissue in 75% or more of their breasts are 4–6 times more likely to develop breast

women undergo self-care.

202 Breast Cancer and Surgery

follow-up after therapy is a caring breast cancer approach.

**2. Caring for patient in breast cancer diagnosis**

following groups are at risk of developing breast cancer [2]:

first cancer or in the other breast.

diagnosed before menopause.

a higher risk for breast cancer:

a tumor suppressor gene.

ian, and testicular cancers.

cer have mutations of this gene.

cancer, gastrointestinal cancers, and thyroid cancer.


a small amount of estrogen. Having more fat tissue can increase estrogen levels and so increase the chance that breast cancer will develop.

with cancer may increase feelings of pain, interfere their ability to sleep, cause nausea and vomiting, and interfere with their quality of life. And the severe anxiety may even shorten the

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Interviewing some breast cancer patients reported that their anxiety is characterized by a number of typical symptoms and signs such as shivering or tremor. They find that their feelings of anxiety increase or decrease at different times. They may become more anxious as cancer spreads or treatment becomes more intense. The level of anxiety experienced by one person may differ from the level of anxiety experienced by another. Anxiety in breast cancer patients is associated with death anxiety, fear of death as a result of their symptoms [4].

Caseness in depression significantly increased in the first year of breast cancer diagnosis from baseline (18.5%) to 4 months (21.5%) but decreased to 15.3% at 12 months [5, 6]. This is in accordance with other studies that majority of women newly diagnosed with early breast cancer reported clinical or severe depressive symptoms. The patients presented a controlled emotional coping style. Anger suppression might play a unique role in depressive symptoms among women newly diagnosed with breast cancer [7]. Anxiety is a more significant psychological state that contributed to the feeling of distress in breast cancer than depression [8]. So on the stage diagnosis, the health team should be concern about management of anxiety. Education in depressed breast cancer patients is adjusted for depression and patient characteristics. Psychoeducation in groups is an intervention given to overcome depression [9]. The role and function of the patient in the family, the pattern of family-patient interaction, the cultural structure in the community, and the religious value of the patient affect the acceptance of breast cancer patients. The severity of depression cannot be separated from the type of cancer suffered. Patients with no history of cancer in the family experienced more severe depression than had a family history of cancer [10]. The severity of the patient's breast cancer

The most common types of breast cancer diagnoses are inflammatory breast cancer, Paget disease of the nipple, and triple-negative breast cancer [11–14]. Explanations of each type of

Inflammatory breast cancer develops when cancer cells block the lymph vessel; the breast becomes red and swollen. Inflammatory breast cancer develops more often in younger women and women of African ancestry. Inflammatory breast cancer is rare and aggressive, which means that it grows and spreads quickly. In most cases, inflammatory breast cancer has already spread to the lymph nodes or other organs when it is diagnosed. The most common symptom of inflammatory breast cancer is a change to the color of the skin on at least one-third of the breast. The skin becomes very red or purplish in color. Other symptoms of

**2.** Dimpled or pitted kin that looks like an orange peel (called peau d'orange)

level is related to the depressed level of the patient.

breast cancer are as follows:

**2.1. Inflammatory breast cancer**

inflammatory breast cancer include:

**1.** A swollen breast

patient's life [4].


During breast cancer diagnosis, patients follow a series of tests. Examinations performed on breast cancer patients include [3]:


Most of the patients and their families face some degree of depression, anxiety, and fear when cancer becomes a part of their lives. Breast cancer patients may experience anxiety at different situations as while undergoing a screening test, waiting for the results, receiving a diagnosis, undergoing treatment, or anticipating a recurrence of their cancer. The anxiety associated with cancer may increase feelings of pain, interfere their ability to sleep, cause nausea and vomiting, and interfere with their quality of life. And the severe anxiety may even shorten the patient's life [4].

Interviewing some breast cancer patients reported that their anxiety is characterized by a number of typical symptoms and signs such as shivering or tremor. They find that their feelings of anxiety increase or decrease at different times. They may become more anxious as cancer spreads or treatment becomes more intense. The level of anxiety experienced by one person may differ from the level of anxiety experienced by another. Anxiety in breast cancer patients is associated with death anxiety, fear of death as a result of their symptoms [4].

Caseness in depression significantly increased in the first year of breast cancer diagnosis from baseline (18.5%) to 4 months (21.5%) but decreased to 15.3% at 12 months [5, 6]. This is in accordance with other studies that majority of women newly diagnosed with early breast cancer reported clinical or severe depressive symptoms. The patients presented a controlled emotional coping style. Anger suppression might play a unique role in depressive symptoms among women newly diagnosed with breast cancer [7]. Anxiety is a more significant psychological state that contributed to the feeling of distress in breast cancer than depression [8]. So on the stage diagnosis, the health team should be concern about management of anxiety.

Education in depressed breast cancer patients is adjusted for depression and patient characteristics. Psychoeducation in groups is an intervention given to overcome depression [9]. The role and function of the patient in the family, the pattern of family-patient interaction, the cultural structure in the community, and the religious value of the patient affect the acceptance of breast cancer patients. The severity of depression cannot be separated from the type of cancer suffered. Patients with no history of cancer in the family experienced more severe depression than had a family history of cancer [10]. The severity of the patient's breast cancer level is related to the depressed level of the patient.

The most common types of breast cancer diagnoses are inflammatory breast cancer, Paget disease of the nipple, and triple-negative breast cancer [11–14]. Explanations of each type of breast cancer are as follows:

## **2.1. Inflammatory breast cancer**

a small amount of estrogen. Having more fat tissue can increase estrogen levels and so

**l.** Physical inactivity. Physical inactivity increases the risk of breast cancer in both premeno-

**m.** High socioeconomic status. Breast cancer risk is slightly higher for women with higher incomes. This may be because of lifestyle factors that are linked to breast cancer, such as

**n.** Tall adult height. Women who have a slightly higher risk of developing breast cancer after menopause. It is thought that energy intake and diet early in life, which affect adult

During breast cancer diagnosis, patients follow a series of tests. Examinations performed on

**1.** Physical exam. A physical exam allows your doctor to look for any signs of breast cancer.

**3.** Diagnostic mammography. Diagnostic mammography is an x-ray that uses small doses of radiation to make an image of the breast. It is used to follow up on abnormal results of a screening mammography or a clinical breast exam. Mammography can also be used to

**4.** Biopsy. A biopsy is the only definite way to diagnose breast cancer. During a biopsy, the doctor removes tissues or cells from the body so they can be tested in a lab. A report from

**5.** Hormone receptor status testing. Estrogen and progesterone are hormones that can stimulate the growth of breast cancer cells. Hormone receptor status testing looks for estrogen

**6.** HER2 status testing. HER2 status testing is done to find out if breast cancer cells are mak-

**7.** Tumor marker test. Tumor markers are substances found in the blood, tissues, or fluids

**8.** X-ray. An X-ray uses small doses of radiation to make an image of parts of the body on

**9.** Bone scan. Bone scan is used to find out if breast cancer has spread to the bones (called

Most of the patients and their families face some degree of depression, anxiety, and fear when cancer becomes a part of their lives. Breast cancer patients may experience anxiety at different situations as while undergoing a screening test, waiting for the results, receiving a diagnosis, undergoing treatment, or anticipating a recurrence of their cancer. The anxiety associated

the pathologist will confirm whether or not cancer cells are found in the sample.

receptors (ERs) and progesterone receptors (PRs) in the breast cancer cells.

ing more HER2 protein than normal (called overexpression).

film. It is used to find out if breast cancer has spread to the lungs.

height, are the factors that increase the risk, rather than just being tall.

increase the chance that breast cancer will develop.

having children later in life or having fewer children.

pausal and postmenopausal women.

breast cancer patients include [3]:

find an abnormal area during a biopsy.

**2.** Clinical breast exam.

204 Breast Cancer and Surgery

removed from the body.

bone metastasis).

Inflammatory breast cancer develops when cancer cells block the lymph vessel; the breast becomes red and swollen. Inflammatory breast cancer develops more often in younger women and women of African ancestry. Inflammatory breast cancer is rare and aggressive, which means that it grows and spreads quickly. In most cases, inflammatory breast cancer has already spread to the lymph nodes or other organs when it is diagnosed. The most common symptom of inflammatory breast cancer is a change to the color of the skin on at least one-third of the breast. The skin becomes very red or purplish in color. Other symptoms of inflammatory breast cancer include:


have changes in the proteins that triple-negative breast cancers usually do not have. Most

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It is important to note that not all triple-negative breast cancers are basal-like and not all basal-like breast cancers are triple negative. They are two similar, but distinct, subtypes of breast cancer. Scientists have not yet developed one internationally accepted definition of a basal-like breast cancer. But they know that it is different from other types of breast cancer.

Women under the age of 40 and women of African or Asian ancestry have a higher risk of developing triple-negative breast cancer. Basal-like breast cancers are more likely to be found

Many triple-negative and basal-like breast cancers may be called interval cancers because

Most triple-negative and basal-like breast cancers are high-grade, or aggressive, tumors. This means that they tend to grow and spread quickly. Many are diagnosed at a later stage when the cancer has already spread (metastasized) to lymph nodes or other organs. These tumors tend to spread to the brain or lungs more often than breast cancers that are not triple negative. Most triple-negative breast cancers have a less favorable prognosis than other types of breast cancer. Basal-like breast cancers spread differently than other types of breast cancer. They usually spread to the bloodstream, brain, and lungs. They do not spread to the lymph nodes or the

When the patient is diagnosed with breast cancer, a feeling of sadness and fear arises, sad because she did not think she will be diagnosed with breast cancer and will lose her breast

Role changes begin to occur in women undergoing diagnosis. The role of mother who takes care of her children is time-consuming. Some patients still have children less than 2 years old, so there is a feeling of guilt for not being able to persecute. The role of wife in serving the husband is disturbed because of his physical condition. Women can still meet the sexual needs of couples but the frequency is reduced. This role change affects self-acceptance as a woman. The reaction of a patient diagnosed with breast cancer is to accept, deny, blame yourself, and

Feeling sad about the diagnosis of cancer that the patient takes requires resistance from yourself so as not to get sucked in sorrow. Patients should have the power to deal with perceived problems. The speed of cancer treatment is proportional to the rate of cancer development itself; the sooner the patient decides to overcome her cancer, the closer she gets in handling it. Psychological support is needed for patients to gain confidence in themselves; the patient believes that the cancer she faces can heal. Family and people closest to her are part of a meaningful social support for patients. Various forms of psychological support, among others, are always present to accompany patients at the time of cancer management. Methods of psychological support, among others, are crisis interventions, psychological counseling, self-support groups, relaxation, and suggestive psychotherapy [17]. The presence of people who are meaningful for the life of the patient will give its own strength, increasing the efficacy

they can develop between regularly scheduled screening mammography.

basal-like breast cancers are invasive ductal carcinomas.

in younger women and in women of African ancestry.

bones as often as other types of breast cancer.

withdraw [16].

due to surgery and patient's fear of illness and death [15].


The symptoms of inflammatory breast cancer are very similar to the symptoms of infection in the breast tissue (mastitis), which is more common in breastfeeding women.

#### **2.2. Paget disease of the breast**

Paget disease of the breast is a rare type of breast cancer. It develops as a rash or other skin changes on the nipple, usually on only one breast. This is more common in women over the age of 50. Most women with Paget disease also have invasive ductal carcinoma or ductal carcinoma in situ (DCIS). The cancer can then spread to the dark-colored skin around the nipple (called the areola).

Paget disease of the breast usually causes changes to the nipple, including:


#### **2.3. Triple-negative breast cancer**

Many breast cancer cells have receptors for estrogen or progesterone. They may also have receptors for a protein called HER2 (also called ERBB2). Triple-negative breast cancer means that the cancer cells do not have any of these receptors. Because it does not have any of these receptors, triple-negative breast cancer is considered a separate type of breast cancer with its own treatment options. Most triple-negative breast cancers are invasive ductal carcinoma. Ductal carcinoma in situ (DCIS) may also be triple negative.

Basal-like breast cancer is similar to triple-negative breast cancer because the cancer cells often do not have receptors for estrogen, progesterone, and HER2. But basal-like breast cancer cells have changes in the proteins that triple-negative breast cancers usually do not have. Most basal-like breast cancers are invasive ductal carcinomas.

**3.** Thickened skin or breast tissue

**7.** Tenderness or pain in the breast

**2.2. Paget disease of the breast**

**1.** Crusting, scaling, or flaking

**2.** Redness of the nipple and areola

**2.3. Triple-negative breast cancer**

**5.** The nipple turning inward, or becoming inverted

Ductal carcinoma in situ (DCIS) may also be triple negative.

**9.** A lump in the armpit (called the axilla) or near the collarbone

the breast tissue (mastitis), which is more common in breastfeeding women.

Paget disease of the breast usually causes changes to the nipple, including:

**6.** The nipple becoming flat a lump in the breast, often near or under the nipple

Many breast cancer cells have receptors for estrogen or progesterone. They may also have receptors for a protein called HER2 (also called ERBB2). Triple-negative breast cancer means that the cancer cells do not have any of these receptors. Because it does not have any of these receptors, triple-negative breast cancer is considered a separate type of breast cancer with its own treatment options. Most triple-negative breast cancers are invasive ductal carcinoma.

Basal-like breast cancer is similar to triple-negative breast cancer because the cancer cells often do not have receptors for estrogen, progesterone, and HER2. But basal-like breast cancer cells

inverted nipple)

206 Breast Cancer and Surgery

**8.** Itching or burning

(called the areola).

**3.** Burning or itching

**4.** Bleeding or discharge

**4.** A breast that feels warm to the touch **5.** An increase in the size of the breast

**6.** Changes to the nipple such as a nipple that suddenly starts to point inward (called an

The symptoms of inflammatory breast cancer are very similar to the symptoms of infection in

Paget disease of the breast is a rare type of breast cancer. It develops as a rash or other skin changes on the nipple, usually on only one breast. This is more common in women over the age of 50. Most women with Paget disease also have invasive ductal carcinoma or ductal carcinoma in situ (DCIS). The cancer can then spread to the dark-colored skin around the nipple It is important to note that not all triple-negative breast cancers are basal-like and not all basal-like breast cancers are triple negative. They are two similar, but distinct, subtypes of breast cancer. Scientists have not yet developed one internationally accepted definition of a basal-like breast cancer. But they know that it is different from other types of breast cancer.

Women under the age of 40 and women of African or Asian ancestry have a higher risk of developing triple-negative breast cancer. Basal-like breast cancers are more likely to be found in younger women and in women of African ancestry.

Many triple-negative and basal-like breast cancers may be called interval cancers because they can develop between regularly scheduled screening mammography.

Most triple-negative and basal-like breast cancers are high-grade, or aggressive, tumors. This means that they tend to grow and spread quickly. Many are diagnosed at a later stage when the cancer has already spread (metastasized) to lymph nodes or other organs. These tumors tend to spread to the brain or lungs more often than breast cancers that are not triple negative. Most triple-negative breast cancers have a less favorable prognosis than other types of breast cancer.

Basal-like breast cancers spread differently than other types of breast cancer. They usually spread to the bloodstream, brain, and lungs. They do not spread to the lymph nodes or the bones as often as other types of breast cancer.

When the patient is diagnosed with breast cancer, a feeling of sadness and fear arises, sad because she did not think she will be diagnosed with breast cancer and will lose her breast due to surgery and patient's fear of illness and death [15].

Role changes begin to occur in women undergoing diagnosis. The role of mother who takes care of her children is time-consuming. Some patients still have children less than 2 years old, so there is a feeling of guilt for not being able to persecute. The role of wife in serving the husband is disturbed because of his physical condition. Women can still meet the sexual needs of couples but the frequency is reduced. This role change affects self-acceptance as a woman. The reaction of a patient diagnosed with breast cancer is to accept, deny, blame yourself, and withdraw [16].

Feeling sad about the diagnosis of cancer that the patient takes requires resistance from yourself so as not to get sucked in sorrow. Patients should have the power to deal with perceived problems. The speed of cancer treatment is proportional to the rate of cancer development itself; the sooner the patient decides to overcome her cancer, the closer she gets in handling it. Psychological support is needed for patients to gain confidence in themselves; the patient believes that the cancer she faces can heal. Family and people closest to her are part of a meaningful social support for patients. Various forms of psychological support, among others, are always present to accompany patients at the time of cancer management. Methods of psychological support, among others, are crisis interventions, psychological counseling, self-support groups, relaxation, and suggestive psychotherapy [17]. The presence of people who are meaningful for the life of the patient will give its own strength, increasing the efficacy


high blood pressure, and other heart problems. Emotional signs may include feeling tired, unwell, and overly sensitive. Activities to reduce stress are exercise regularly, meditate to practice deep breathing, listen to music or read, talk to someone, ask others to help, try to rest and get enough sleep, eat nourishing food to give energy and keep well, and take time

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Some breast cancer treatments have side effects that affect the heart; the most common side effects are heart dysfunction, chest pain, and irregular heartbeat [20]. Heart dysfunction can occur during cancer treatment or any time up to 2 years after treatment is finished. The symptoms of heart dysfunction are difficulty keeping up level activity, a bloated feeling around the abdomen, feeling less hungry, swelling of ankles and feet, feeling dizzy when changing

Patients need basic information about chemotherapy, side effects, and problem-solving skills during therapy. Fulfillment of chemotherapy information prevents depression and anxiety in breast cancer patients [21]. Patients undergoing radiotherapy experience various problems such as skin changes, burning scars, and edema. Patients who dissected experienced losing her breasts affected her body image. Changes in patients with radiotherapy and surgery lead to changes in self-image that affect the psychological health of the patient. After breast surgery studies show that mastectomy as surgical treatment for breast cancer may negatively

Breast cancer patients maintain a healthy life with various activities. **Table 2** describes healthy

In fact, patients who receive both often have less severe symptoms, have better quality of life, and report they are more satisfied with treatment [23]. So, they needed symptom management, supportive care, or palliative care. Palliative care is given at every step of treatment process. In this part, the patients accept support from caregivers, family, and friends [24]. The other person such as volunteer, clergy, social group providing support for the patient's

Increasing physical activity after treatment can help: strengthen muscles, improve fitness level, lower

emotional and social needs, spiritual needs or concern and practical needs.

Be active Try to stay active during cancer treatment; exercise or do physical activity each day

Limit food and drinks that are high in calories, fat, sugar, and sodium

position, and shortness of breath, at rest or when active.

affect a woman's body image and her self-image [22].

blood pressure, and give more energy Eat well Eat a variety of foods from the four food groups each day Read food label to choose healthier foods

Drink little or no alcohol Do not smoke Limited smoking or stop smoking

**Table 2.** Healthy living for breast cancer patients during treatment.

activity for the heart of breast cancer patient.

**Activities**

to care for self.

**Healthy living**

**Table 1.** Activities to take care of themselves for breast cancer patients.

of patients to undergo therapy. Patients will follow various follow-up measures of various cancer intervention options. The nearest mentoring gives meaning to the patient so that the patient has hope for the success of the follow-up to be followed.

Patient should care for themselves to overcome breast cancer problems. **Table 1** shows some of the activities that breast cancer patients do to take care of themselves [18].

Caring shown in these conditions, such as empathy with women, do not blame that women who suffer from breast cancer because of the risks that exist in her. The presence of the nearest person as the person who gives attention to the woman reinforces her.
