Contact Hours: 3
This online independent study activity is credited for 3 contact hours at completion.
Course Purpose
The purpose of this course is to provide an overview of breast cancer types, symptoms, stages and treatment modalities.
Overview
Breast cancer is the most common cancer diagnosed in women. Breast cancer commonly spreads to the nearby lymph nodes but can further spread throughout the body to the bones, lungs, brain, and liver via lymph nodes and blood vessels. This course will review the different breast cancer types, their diagnosis, staging, and treatment, lifestyle modifications, and nursing considerations necessary to reduce symptoms and reduce the risk of breast cancer recurrence.
Course Objectives
Upon completion of the independent study, the learner will be able to:
- Describe the various types of breast cancer
- Review diagnostic tests for breast cancer
- Differentiate the stages and characteristics of breast cancer
- Understand the treatment options for various breast cancer types
- Understand the lifestyle modifications to reduce breast cancer risks
Policy Statement
This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.
Disclosures
Fast CE For Less, Inc. and its authors have no disclosures. There is no commercial support.
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Early breast cancer screening is important for early diagnosis and to prevent disease progression into an aggressive state.10 The type of diagnostic procedure used is based on the patient’s age, overall health, signs, and symptoms, suspected cancer type, and results of previous medical tests.2 Generally, for breast cancers, a triple assessment method is required, such as
Clinical evaluation includes an examination of a lump or nodule in the breast.2 Diagnostic procedures are also recommended when an abnormal mass is found through screening tests.2 However, it is important to note that most breast cancer types show no outward symptoms during the initial stages; thus, individuals with risk factors are recommended routine screening for early detection. Common risk factors for breast cancer include: 2
Imaging tests are often done before the patient shows any signs or symptoms and may help in early detection, decreasing morality, and identifying people with a high risk of developing breast cancer.3 Most effective imaging tests include
- denser breasts in people less than 40 years old.10 In fact, mammography may not detect existing breast cancer in up to 15% of people tested.2 The sensitivity of the imaging test depends on the individual’s age, gender, ethnicity, personal history, and technical quality.10 As a result, digital mammography has been extensively studied and has shown positive results. It uses intravenous iodinated contrast injection and has improved detection accuracy compared to traditional mammography.2,10
- and is suggested only in patients with a high risk of breast cancer development or those that cannot have mammography, such as pregnant women.10
- .2 It uses a strong magnetic field with RF signals and a contrast agent to create different cross-section images of the breast. It is less specific, but sensitive to small tumors.10
Once imaging tests indicate that cancer is present, a biopsy is conducted to make a confirmed diagnosis.2 Different types of biopsies are available based on the tissue sample, technique, and needle size used, such as:
- Fine needle aspiration – Uses a thin needle to remove small cells.
- Core needle – The preferred biopsy technique. It uses a wider needle for a larger sample.2 After detection, cancer biomarkers to detect the presence of estrogen, progesterone, and HER2-positive protein are conducted.2
- Image-guided – Uses ultrasound, mammography, or MRI to guide a needle to the lump or calcified mass.
- Surgical – Removes the largest amount of tissue and is not recommended before a confirmed diagnosis.
- – Used to determine if cancer has spread to the surrounding lymph nodes.2
Breast cancer is the most common cancer diagnosed in women, making it the second most common cause of death in women worldwide.1 Breast cancer commonly spreads to the nearby lymph nodes but can further spread throughout the body to the bones, lungs, brain, and liver via lymph nodes and blood vessels.2 Thus, breast cancer can start and recur in different parts, such as lobules, ducts, nipples, blood vessels, and lymph nodes.3 Based on this, there are multiple breast cancer types and, each varying in its diagnosis, symptoms, and treatment.3
This course will review the different breast cancer types, their diagnosis, staging, and treatment, lifestyle modifications, and nursing considerations necessary to reduce symptoms and reduce the risk of breast cancer recurrence.
Breast Cancer Types, Diagnosis, and Staging
There are various types of breast cancer that are diagnosed based on the areas affected. They are also classified as invasive (spread to surrounding tissues, organs, and blood vessels) or non-invasive (does not grow beyond the milk ducts or lobules).2 Generally, most breast cancers are divided into two major types:3
- Ductal carcinoma in situ (DCIS)
- Lobular carcinoma in situ (LCIS)
Ductal carcinoma is the most common type of cancer and can be invasive and non-invasive.4 Ductal Carcinoma in Situ (DCIS) is a non-invasive cancer that is restricted to the lining of the milk ducts and does not spread to the surrounding breast tissues.4 It is a precursor to invasive breast cancer and can grow and spread outside the ducts into other parts of the body.4,5
Risk factors include family history, age, high mammographic density, parity, high body mass index, alcohol consumption, and other hormonal factors.5 Moreover, it has been researched that BRCA1 and BRCA2 mutation carriers develop breast cancer frequently and at an earlier age.5 Due to the possibility of progressing to invasive breast cancer being high, a targeted treatment plan is necessary.
Invasive DCIS breast cancer grows into a cohesive mass and appears as a small discrete lump or abnormalities in the mammogram. It accounts for 50 to 70% of all invasive breast cancer.1 Different types of invasive ductal breast cancer are named according to their features. For instance, if the invasive cells organize themselves into tiny glands with a plain epithelial layer, they are called infiltrating tubular carcinoma. Sometimes these cells release a large amount of mucus and surrounds itself in it, and these growths are known as mucinous or colloid tumors.1
Generally, there are no symptoms associated with ductal carcinoma in situ. It is commonly found by a mammogram and looks like a cluster of white spots. In a minority of cases, an abnormal lump is found, or nipple discharge occurs.6
Lobular carcinoma is not considered breast cancer but rather a risk for developing invasive breast cancer in the future.1 It is characterized by cancer-like cells conforming to the lining of the breast’s lobules (milk-producing glands), with expanded and filled acini.1,7 It does not invade through the wall of the lobules.7 There are different types of LCIS breast cancer, such as
- Pleomorphic – The cancer cells lining the lobules are larger and look more abnormal
- Classic – The cancer cells lining the lobules are small, look similar in size, and are discrete.
- Florid – The cancer cells lining the lobules have formed a huge mass with central necrosis (dead cells in the center).7
Women with LCIS have a 7 to 12% higher risk of developing invasive breast cancer.7 The invasive subtype accounts for 10% of all breast cancers; thus, doctors recommend regular follow-up and screening tests for LCIS patients.7
Diagnosis is different for cancer types. For instance, in classic LCIS, no lumps are generally formed, or any changes observed with a mammogram, and diagnosis is only possible through a biopsy for another condition.7 In pleomorphic and florid LCIS, a lump may or may not form.7
Like ductal carcinoma in situ, this non-invasive breast mass shows no apparent symptoms that can direct toward a diagnosis. Thus, it is a silent disease. Frequent screenings are recommended for individuals with a family history of breast cancer or other risk factors, as it can progress to invasive breast cancer.1
Breast cancers are further divided based on the proteins and genes they produce.3 Some common subtypes include:
Breast cancers that express either one or both estrogen and progesterone hormone receptors are termed hormone receptor-positive. They can occur at any age but are most common in women after menopause.3 It has a high prevalence rate, with two-thirds of all breast cancers being hormone receptor-positive. Treatment is usually done through hormone therapy.3
Around 15 to 20% of all breast cancers have a higher concentration of the HER2 protein; such cancers are termed HER2 positive. The protein helps cancer cells to grow quickly and spread faster and wider than HER2-negative breast cancers.8 Diagnosis is important to find the best treatment action plan. Diagnosis can be made through an immunohistochemistry (IHC) test or fluorescence in Situ hybridization (FISH) test to check the protein concentration.7 Treatment is focused on HER2-targeted agents.3,8
Triple Negative Breast Cancer accounts for 12 to 17% of all breast cancers and has a poor prognosis.9 It is characterized by the absence of the estrogen and progesterone hormones and the lack of overexpression and amplification of the HER2 protein.8 It affects young women and has an aggressive nature.8 It is also common in Black and Hispanic women or patients with BRCA1 gene mutation.3 Many research studies have shown immunotherapy to be fruitful for triple-negative breast cancer.8
Breast cancers are also categorized based on their tumor grades and staging. Less common breast cancer types include: 3,4
- Papillary and micropapillary
- Mucinous
- Tubular
- Metaplastic
- Medullary
- Inflammatory breast cancer
- Paget’s disease
Early breast cancer screening is important for early diagnosis and to prevent disease progression into an aggressive state.10 The type of diagnostic procedure used is based on the patient’s age, overall health, signs, and symptoms, suspected cancer type, and results of previous medical tests.2 Generally, for breast cancers, a triple assessment method is required, such as
Clinical evaluation includes an examination of a lump or nodule in the breast.2 Diagnostic procedures are also recommended when an abnormal mass is found through screening tests.2 However, it is important to note that most breast cancer types show no outward symptoms during the initial stages; thus, individuals with risk factors are recommended routine screening for early detection. Common risk factors for breast cancer include: 2
Imaging tests are often done before the patient shows any signs or symptoms and may help in early detection, decreasing morality, and identifying people with a high risk of developing breast cancer.3 Most effective imaging tests include
- denser breasts in people less than 40 years old.10 In fact, mammography may not detect existing breast cancer in up to 15% of people tested.2 The sensitivity of the imaging test depends on the individual’s age, gender, ethnicity, personal history, and technical quality.10 As a result, digital mammography has been extensively studied and has shown positive results. It uses intravenous iodinated contrast injection and has improved detection accuracy compared to traditional mammography.2,10
- and is suggested only in patients with a high risk of breast cancer development or those that cannot have mammography, such as pregnant women.10
- .2 It uses a strong magnetic field with RF signals and a contrast agent to create different cross-section images of the breast. It is less specific, but sensitive to small tumors.10
Once imaging tests indicate that cancer is present, a biopsy is conducted to make a confirmed diagnosis.2 Different types of biopsies are available based on the tissue sample, technique, and needle size used, such as:
- Fine needle aspiration – Uses a thin needle to remove small cells.
- Core needle – The preferred biopsy technique. It uses a wider needle for a larger sample.2 After detection, cancer biomarkers to detect the presence of estrogen, progesterone, and HER2-positive protein are conducted.2
- Image-guided – Uses ultrasound, mammography, or MRI to guide a needle to the lump or calcified mass.
- Surgical – Removes the largest amount of tissue and is not recommended before a confirmed diagnosis.
- – Used to determine if cancer has spread to the surrounding lymph nodes.2
Diagnosis is also useful in determining the breast cancer’s stage and if the lymph nodes and distant body parts are affected.2 Cancer staging also helps predict a patient’s prognosis, recovery chances, and possible treatment options.2 The most common method of staging used is the TNM system staging, which can be defined as
- Tumor (T) – what is the tumor size?
- Node (N) – has it spread to the lymph nodes?
- Metastasis (M) – has it spread to distant body parts?2
Based on the tumor grade, results of screening tests, and TNM system, doctors group cancers into different stages – from 0 to IV.
Table 1: Stages of Breast Cancer2
Sentinel Lymph Node in Breast Cancer
When cancer metastasizes from its original site, the first group of lymph nodes it reaches are called the sentinel lymph nodes. In cases of breast cancer, axillary lymph nodes (lymph nodes under the underarms) are sentinel lymph nodes.2
Sentinel lymph nodes play a major prognostic role in breast cancer.11 They help stage the disease and create a suitable treatment action plan.11 Generally, in a histological examination, if the presence of a tumor is negative in the sentinel lymph node ganglion, chances are, in 99% of cases, it is also negative for other lymph nodes.11 Sentinel lymph nodes are typically affected in the following stages:
- T1a (4.3%)
- T1b (19.5%)
- T1c (23.8%)
- T2 (48.9%)
- T3 (66.7%).11
Thus, examining the axillary lymph nodes has become a gold standard for evidence of metastatic invasion. At least 3 lymph nodes must show signs of metastasis to change the staging of the disease. The standard histological analysis technique is quite complex but, if executed perfectly, can detect the following:
- Macro metastases: high risk of axillary residual disease (other positive lymph nodes frequently observed).
- Micro metastases: chances of an axillary residual disease in 10% of patients.
- Isolated tumor cells: have no proven prognostic importance and are rarely associated with an axillary residual disease.11
In breast cancer, a multidisciplinary team consisting of oncologists, specialized surgeons, radiologists, and pathologists work together to create a personalized treatment plan for the patient, as each cancer case is different.2 When developing a treatment plan for breast cancer, multiple factors are taken into consideration, including:2
Although each patient receives a customized treatment plan, standard treatment options are available for early-stage and advanced cancer types.
Ductal carcinoma in situ (DCIS)
Treatment options for DCIS breast cancer depend on the physician and patient preference. Surgery is recommended, and then additional treatments to manage early-stage cancer and prevent a recurrence.2
In most breast cancer cases, women prefer surgery; a wide-local excision (WLE)/lumpectomy or mastectomy.5 Surgery involves the removal of the tumor and a small margin of the surrounding healthy tissue to prevent a recurrence. There are two types of surgical options available.2 A lumpectomy involves the removal of the tumor and a cancer-free margin of healthy tissue around the tumor.2 Radiation therapy is recommended after a lumpectomy in DCIS and shows a 19 to 31% reduction in ipsilateral recurrences compared with contralateral tumors (4–7%) at 10 years when treated with surgery alone.5
On the other hand, a mastectomy involves the removal of the entire breast.2 Patients can preserve their skin or nipple, but it depends on the tumor size compared to the breast.2
In early-stage cancer that has not reached the lymph nodes, external beam radiation therapy is given after a lumpectomy for 3 to 4 weeks. If cancer is present in the lymph nodes, it can increase up to 5 to 6 weeks. The duration depends on the tumor size, and initially, the whole breast is targeted. Later, only focused radiations are given to prevent a recurrence.2
In case of a mastectomy, radiation therapy is given daily for 5 to 6 weeks. It can be given before or after surgery.2
If DCIS is hormone-receptor-positive, hormonal therapy is considered.6 Endocrine therapy is also known as endocrine therapy or anti-estrogen therapy.6 It blocks hormone actions or lowers the level of hormones in the body.2 Different types of hormonal therapies are available based on the drugs given, such as Tamoxifen, ablation, or Aromatase inhibitors (AIs).2 The choice between them also depends on whether or not the patient is in menopause.2
Hormonal therapy can also be given before surgery (neoadjuvant therapy) to shrink the tumor, lower the risk of recurrence, and make surgery easier.2
Lobular Carcinoma in Situ (LCIS)
Lobular Carcinoma in Situ (LCIS) is termed as a pre-cancer, and although there are chances of it progressing into invasive breast cancer, treatment is not required.7 If the LCIS is diagnosed as florid and pleomorphic after a needle biopsy, excision biopsy, or breast-conserving surgery is recommended.7
For women with multiple risk factors on top of pleomorphic and florid LCIS, removing both breasts by mastectomy is recommended to prevent a recurrence.7
In patients with HER2-positive breast cancer that is 2 cm in size or larger and involves lymph nodes, neoadjuvant chemotherapy with a targeted drug is recommended.2 Aside from this, another targeted drug therapy involves administering pertuzumab with trastuzumab before surgery.2
In patients with early-stage HER2-positive breast cancer with a 1 cm or smaller tumor size, and no lymph nodes involvement, neoadjuvant chemotherapy or HER2-targeting drugs should not be routinely offered outside of a clinical trial.2
Triple-Negative Breast Cancer
- Neoadjuvant chemotherapy – Is the standard of care for inoperable or advanced Triple-Negative Breast Cancer (TNBC). Patients are more likely to achieve a pathological complete response (pCR) and improve their chances of disease-free survival.9 According to GeparTrio, pCR rates up to 57% for TNBC are managed with neoadjuvant anthracyclines, cyclophosphamide, and taxanes.9
- Immunotherapy – Pembrolizumab in combination with anthracycline and taxane chemotherapy increases pCR rates and has shown incredible results; up to a 90% increase in phase 1b and 2 clinical trials.9
Survival rates refer to the percentage of patients that can survive the effects of cancer. Survival statistics are based on a large group of people. Still, it is important to remember that no two patients are exactly alike, and thus we cannot say for sure how an individual will react to a treatment or drug.12 However, the prognosis for breast cancer is good and has an overall 91% 5-year survival rate.12
In the United States, the 5-year relative survival rate for women with non-metastatic invasive breast cancer is 91%, and the 10-year relative survival rate is 85%.2 However, this percentage is true for early-stage breast cancer or one that is only localized in the breast. If cancer has spread to the nearby lymph nodes, the 5-year relative survival rate is 86%.2 Moreover, if cancer has spread to distant body parts, the 5-year relative survival rate is 30%.2
Regarding recurrence, women with early-stage breast cancer have a higher chance, around 7 to 11%, of developing local recurrence 5 years after treatment.13 Other risk factors also increase the chances of recurrence and metastasis, such as family history and BRCA1 and BRCA2 gene mutation.13
There are 3 major types of recurrent breast cancer, including:
- Local – The cancer returns to the same site as the original diagnosis.
- Regional – The cancer returns to the nearby lymph nodes or chest wall near the originally diagnosed site.
- Distant – Also known as metastatic breast cancer, where the cancer has traveled to distant body parts from the original tumor site via the lymphatic system and bloodstream.13
Metastatic breast cancer refers to stage IV breast cancer, when the cancer has spread to distant body parts from the original tumor site.14 It is also known as advanced breast cancer and can spread to any body part. However, the most common parts of the body include the brain, bones, liver, and lungs.14 The cancer is named after its original tumor site, also known as the primary site.14
They are usually diagnosed when a person has received treatment for a previous non-metastatic breast cancer. In some cases, a patient’s first diagnosis reveals cancer has already spread to distant body parts and is termed de-novo metastatic breast cancer or stage IV breast cancer.14
Symptoms of metastatic breast cancer depend on the area of recurrence. For instance, if the cancer has entered the spine, lungs, or liver, patients can experience fatigue, cough, shortness of breath, and back pain.15 If cancer has spread to the brain, symptoms like convulsions, headache, difficulty in speaking or changes in vision, and mood changes are common.15
Common symptoms experienced by patients of stage IV breast cancer include:15
- Back or neck pain
- Fatigue
- Headache
- Malaise
- Pain in the bones
- Seizures
- Vision changes
Multiple risk factors can increase an individual’s chances of developing breast cancer. Although there is no proven way to prevent breast cancer, researchers have found various lifestyle modifications that can decrease mortality rates and improve prognosis. The following are some key prevention and lifestyle modifications for breast cancer patients:
Multiple studies have researched the effect of body weight on breast cancer prognosis and developed different mechanisms. For instance, increased body weight increases circulating sex hormones, proinflammatory cytokines, and insulin-like growth factors. Another theory concludes that any 3 of the following 5 components creates a metabolic syndrome and increases mortality: 16
- Abdominal obesity
- High plasma glucose level
- High triglyceride levels
- Hypertension
- Low level of high-density lipoproteins
Research shows that women who gain weight before or after diagnosis have a poor prognosis.16 Average weight gain is around 2.5 to 5 kg but can go up to 10 kg.16 Thus, by preventing weight gain and choosing a healthy diet, women can increase their survival rate.16
The integration of physical activity into a daily routine has the most positive and prominent effects on mortality rates. Multiple studies have shown that women participating in recreational activities significantly reduced their mortality rates.16 This is because physical activity promotes reduced inflammation, lowered endogenous hormone levels, and reversal of insulin resistance.16
According to the American Cancer Society, breast cancer patients should engage in:16
- At least 30 minutes of moderate-intensity physical activity, 5 days a week
- Or 75 minutes of vigorous exercise, combined with 2-3 weekly strength training sessions.
Intake of lipids and carbohydrates also influences hormonal and metabolic processes and can increases the chances of recurring breast cancer. Although it is difficult to pinpoint macro and micronutrients, multiple studies have shown that high consumption of dairy and saturated fats increases mortality.16 Diets involving high concentrations of vegetables, fruits, whole grains, and chicken are considered healthy and beneficial. Patients can also opt for Mediterranean diets.16
Smoking and Alcohol Consumption
Although there is no strong evidence to suggest that avoiding smoking can decrease mortality rates, a few studies support the theory and show positive results. For instance, a study found that women with breast cancer who continued to smoke after treatment had a higher chance of dying from the disease.16 Whereas women who quit smoking after breast cancer treatment had a significantly lower rate of death from breast cancer or respiratory cancer.16 Similarly, reducing alcohol consumption to one drink per day or less is sufficient to decrease mortality rates.16
For many decades, the cancer care continuum concept has been used as a framework to help nurses navigate breast cancer care at different stages and in different roles and responsibilities.17 The nurses’ role during different cancer stages include:
- Prevention and early detection
- Nurses can intervene early and implement lifestyle changes such as increased physical activity and reduction in tobacco use and alcohol consumption.
- Nurses should also be educated in visual inspection to detect common signs and provide education to patients on self-exams and having routine screenings.17
- Surgery
- Oncology nurses should be involved in the pre-operative, post-operative, and survivorship stages to improve patient outcomes.17
- Radiotherapy
- Nurses should be well-versed in the principles of radiobiology, physics, and novel complex treatments to offer supportive care to the patient and caregivers.
- In radiotherapy, a nurse’s role includes pre-treatment assessment, symptom assessment and management, care coordination, psychosocial support, and education and research.17
- Systemic anti-cancer therapy (SACT)
Nurses should collaborate with pharmacists and oncologists for successful management of patients receiving SACT. This includes patient assessment, education, symptom management, and supportive care.17
Researchers continue to work on early-stage and locally-advanced breast cancer, its diagnosis, early treatment, and ways to prevent it.2 Core research areas include evaluating the best surgery methods, testing new drugs and treatments, finding alternative approaches to reconstructive surgery, and learning more about the social and emotional factors while developing a treatment plan.2
Every breast cancer patient is different, and a multidisciplinary team is required to create a personalized treatment plan. This includes clinical oncologists, oncology and chemotherapy nurses, and specialized doctors for recurrent stage IV breast cancer. Nurses play a major role in developing awareness and offering supportive and palliative care to patients throughout the disease process. For instance, after treatment, patients should be advised to follow up for life to detect early recurrence or spread.1 Moreover, women should get regular mammograms and be informed if suspicious results are received.1 Providing education to patients on measures to reduce breast cancer risks, in conjunction with regular examinations, greatly reduces mortality associated with breast cancer.
- Alkabban FM, Ferguson T. Breast Cancer. PubMed. Published 2022. https://www.ncbi.nlm.nih.gov/books/NBK482286/#:~:text=Breast%20cancer%20is%20the%20most
- View All Pages. Cancer.net. Published 2020. https://www.cancer.net/cancer-types/breast-cancer/view-all
- American Cancer Society. What is Breast Cancer? Cancer.org. Published November 19, 2021. https://www.cancer.org/cancer/breast-cancer/about/what-is-breast-cancer.html
- CDC. What Is Breast Cancer? Centers for Disease Control and Prevention. Published June 17, 2020. https://www.cdc.gov/cancer/breast/basic_info/what-is-breast-cancer.htm#:~:text=Breast%20cancer%20is%20a%20disease
- Gorringe KL, Fox SB. Ductal Carcinoma In Situ Biology, Biomarkers, and Diagnosis. Frontiers in Oncology. 2017;7. doi:https://doi.org/10.3389/fonc.2017.00248
- Ductal Carcinoma In Situ (DCIS). www.breastcancer.org. https://www.breastcancer.org/types/ductal-carcinoma-in-situ
- Lobular Carcinoma in Situ | LCIS | American Cancer Society. www.cancer.org. https://www.cancer.org/cancer/breast-cancer/non-cancerous-breast-conditions/lobular-carcinoma-in-situ.html#:~:text=Lobular%20carcinoma%20in%20situ%20(LCIS)%20is%20a%20type%20of%20breast
- American Cancer Society. Breast Cancer HER2 Status. Cancer.org. Published 2013. https://www.cancer.org/cancer/breast-cancer/understanding-a-breast-cancer-diagnosis/breast-cancer-her2-status.html
- Bergin ART, Loi S. Triple-negative breast cancer: recent treatment advances. F1000Research. 2019;8:1342. doi:https://doi.org/10.12688/f1000research.18888.1
- Wang L. Early Diagnosis of Breast Cancer. Sensors. 2017;17(7):1572. doi:https://doi.org/10.3390/s17071572
- Bouquet de Jolinière J, Major A, Khomsi F, Ben Ali N, Guillou L, Feki A. The Sentinel Lymph Node in Breast Cancer: Problems Posed by Examination During Surgery. A Review of Current Literature and Management. Frontiers in Surgery. 2018;5. doi:https://doi.org/10.3389/fsurg.2018.00056
- National Cancer Institute. Female Breast Cancer – Cancer Stat Facts. SEER. Published 2018. https://seer.cancer.gov/statfacts/html/breast.html
- Recurrent breast cancer. Cancer Treatment Centers of America. Published June 11, 2019. https://www.cancercenter.com/cancer-types/breast-cancer/types/rare-breast-cancer-types/recurrent-breast-cancer#:~:text=According%20to%20the%20Susan%20G
- Breast Cancer – Metastatic – Introduction. Cancer.net. Published May 19, 2017. https://www.cancer.net/cancer-types/breast-cancer-metastatic/introduction#:~:text=When%20breast%20cancer%20spreads%20to
- Metastatic Breast Cancer. www.hopkinsmedicine.org. Published April 22, 2022. https://www.hopkinsmedicine.org/health/conditions-and-diseases/breast-cancer/metastatic-breast-cancer
- Hamer J, Warner E. Lifestyle modifications for patients with breast cancer to improve prognosis and optimize overall health. Canadian Medical Association Journal. 2017;189(7):E268-E274. doi:https://doi.org/10.1503/cmaj.160464
- Young AM, Charalambous A, Owen RI, et al. Essential oncology nursing care along the cancer continuum. The Lancet Oncology. 2020;21(12):e555-e563. doi:https://doi.org/10.1016/s1470-2045(20)30612-4
To access Breast Cancer, purchase this course or a Full Access Pass.
If you already have an account, please sign in here.
To access Breast Cancer, purchase this course or a Full Access Pass.
If you already have an account, please sign in here.
