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Case 22-2020: a 62-year-old woman with early breast cancer during the covid-19 pandemic, permissions, information & authors, metrics & citations, view options, presentation of case.

Pathological Discussion

Discussion of Management

Management of Breast Cancer before the Covid-19 Pandemic

Upfront surgical options, options for systemic treatment, options for radiation therapy, management of breast cancer during the covid-19 pandemic, approaches to radiation therapy, options for neoadjuvant endocrine therapy in lieu of surgery, alternative scenarios during the covid-19 pandemic, patients with her2-amplified breast cancer, patients with triple-negative breast cancer, patients who have completed neoadjuvant therapy and need surgery, communication with patients during the covid-19 pandemic, final diagnosis, supplementary material, information, published in, translation.

• Breast Cancer
• Clinical Medicine General
• Surgery General
• Treatments in Oncology
• Viral Infections

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• Lee G. Wilke,
• Toan Thien Nguyen,
• Qiuyu Yang,
• Bret M. Hanlon,
• Kathryn A. Wagner,
• Pamela Strickland,
• Eric Brown,
• Jill R. Dietz,
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Patient Case Presentation

Patient Mrs. B.C. is a 56 year old female who is presenting to her WHNP for her annual exam. She had to cancel her appointment two months ago and didn’t reschedule until now. Her last pap smear and mammogram were normal. Today, while performing her breast exam, her nurse practitioner notices dimpling in the left breast as the patient raises her arms over her head. When the NP mentions it to Mrs. B.C. she is surprised and denies noticing it before today. A firm, non-tender, immobile nodule is palpated in the upper quadrant of her breast . The NP then asks Mrs. B.C. how frequently she is performing breast self-exams, she admits to only doing them randomly when she remembers, which is about every few months. She reports no recent or abnormal drainage from her breast. Further examination reveals palpable axillary lymph nodes. 

Mrs. B.C. is about 30 pounds overweight and walks her dog around her neighborhood every morning before work and every evening when she gets home. She reports drinking a glass of white wine before bed each night. She denies any history of tobacco use. She reports use of a combination birth control pill on and off for 25 years until she reached menopause. She is not currently taking any prescription medications. 

Past Medical History

• Menarche (Age 10)
• Post-menopausal (Age 53)
• No other pertinent medical history

Family History:

• Father George- deceased from stroke (75 years old), history of hypertension, CAD, HLD
• Mother Maryanne alive- 76 years old, history of dementia, osteoporosis 
• Brother Michael- alive, 57 years old, history of hypertension, CAD and cardiac stent placement (54 years old)
• Sister, Michelle- alive 53 years old, history of GERD, Asthma
• Brother- Jimmy- alive 50 years old, no past medical history

Social History: 

Mrs. B.C. works Monday-Friday 8am-5pm at the local dentist’s office at the front desk as a schedule coordinator. She is planning to retire in a few years. In her spare time, she is involved in various community efforts to feed the homeless and helps to prepare dinners at her local church one night a week. She also enjoys cooking and baking at home, gardening, and nature photography. 

Mrs. B.C. has two children. Her oldest son, Patrick, is 21 years old and is in his final year of pre-med. He is attending a public university about 2 hours away from home where he lives year-round. As an infant, Patrick was breastfed until 18 months when he self-weaned. Her daughter, Veronica, is 19 years old and lives at home while attending the local branch campus of a state university. She is in her second year of a business degree and then plans to transfer to the main campus next year. When Veronica was an infant she had difficulty latching onto the breast due to an undiagnosed tongue and lip ties resulting in Mrs. BC exclusively pumping and bottle feeding for six months. After six months, Mrs. B.C. was having a hard time keeping up while working and her found her supply diminished. Veronica had begun eating solid foods so Mrs. B.C. switched to supplemental formula, which was a big relief.

Mrs. B.C. was married to her now ex-husband Kent for 26 years. They divorced two years ago when Veronica was a senior in high school. They have remained friends and Kent lives 25 minutes away in a condo with his girlfriend. She also has two brothers who live nearby and a sister who lives out of state. Her 7 nieces and nephews range in age from 9 years old to 26 years old. Her father, George, passed away from a sudden stroke 4 years ago. Her mother, Maryanne, has dementia and is living in a nearby memory care facility. She also has many close friends. 

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Breast cancer case study

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It seems that you like this template, breast cancer case presentation, free google slides theme, powerpoint template, and canva presentation template.

Clinical cases are so convenient, the medical community is always grateful for the information provided. In this occasion, we at Slidesgo have decided to create this new presentation template, focused on breast cancer, so that you can raise awareness about this important topic and help everyone get to know what they can do.

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Nursing Case Study for Breast Cancer

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Natasha is a 32-year-old female African American patient arriving at the surgery oncology unit status post left breast mastectomy and lymph node excision. She arrives from the post-anesthesia unit (PACU) via hospital bed with her spouse, Angelica, at the bedside.  They explain that a self-exam revealed a lump, and, after mammography and biopsy, this surgery was the next step in cancer treatment, and they have an oncologist they trust. Natasha says, “I wonder how I will look later since I want reconstruction.”

What assessments and initial check-in activities should the nurse perform for this post-operative patient?

• Airway patency, respiratory rate (RR), peripheral oxygen saturation (SpO2), heart rate (HR), blood pressure (BP), mental status, temperature, and the presence of pain, nausea, or vomiting are assessed upon arrival. Medication allergies, social questioning (i.e. living situation, religious affiliation), as well as education preference are also vital. An admission assessment MUST include an examination of the post-op dressing and any drains in place. This should be documented accordingly.
• The hand-off should be thorough and may be standardized. Some institutions have implemented a formal checklist to provide a structure for the intrahospital transfer of surgical patients. Such instruments help to standardize processes thereby ensuring that clinicians have critical information when patient care is transferred to a new team. The nurse should also prepare to provide education based on surgeon AND oncologist guidance

What orders does the nurse expect to see in the chart?

• Post-op medications, dressing change and/or drain management, strict I&O, no BP/stick on the operative side (rationale is to help prevent lymphedema – Blood pressure (BP) measurement with a cuff on the ipsilateral arm has been posed as a risk factor for the development of LE after-breast cancer therapy for years, regardless of the amount of lymph node excision.)
• Parameters for calling the surgeon are also important. The nurse should also check for an oncology service consult.

After screening and assessing the patient, the nurse finds she is AAOx4 (awake, alert and oriented to date, place, person and situation). The PACU staff gave her ice due to dry mouth which she self-administers and tolerates well. She has a 20G IV in her right hand. She states her pain is 2 on a scale of 1-10 with 10 being the highest. Her wife asks when the patient can eat and about visiting hours. Natasha also asks about a bedside commode for urination and why she does not have a “pain medicine button”. Another call light goes off and the nurse’s clinical communicator (unit issued cell phone) rings.

The nurse heard in report about a Jackson-Pratt drain but there are no dressing change instructions, so she does not further assess the post-op dressing situation in order deal with everything going on at the moment. She then sits down to document this patient.

Medications ordered in electronic health record but not yet administered by PACU: Tramadol 50 mg q 6 hrs. Prn for mild to moderate pain. Oxycodone 5 mg PO q 4 hrs. Prn for moderate to severe pain (5-7 on 1-10 scale) Fentanyl 25 mcg IV q3hrs. Prn For breakthrough pain (no relieve from PO meds or greater than 8 on 1-10 scale) Lactated Ringers 125 mL/hr IV infusion, continuous x 2 liters Naloxone 0.4-2 mg IV/IM/SC; may repeat q2-3min PRN respiratory rate less than 6 bpm; not to exceed 10 mg

BP 110/70 SpO2 98% on Room Air HR 68bpm and regular Ht 157 cm RR 14 bpm Wt 53 kg Temp 36.°5C EBL 130mL CBC -WNL BMP Potassium – 5.4 mEq/L

What education should be conducted regarding post-op medications?

• New post-op pain guidelines rely less on patient-controlled analgesia (aka “pain medicine button”) than in previous years. Most facilities will have an approved standing protocol (i.e., “Multimodal analgesia and Opioid Prescribing recommendation” guideline) or standing orders. The patient must be instructed on how to rate pain using facility-approved tools (aka “pain scales”). She should also report any medication-related side effects and reinforce there is a reversal medication in case of an opioid overdose.

What are some medical and/or non-medical concerns the nurse may have at this point? If there are any, should they be brought up to the surgeon?

• The nurse may request an anti-emetic such as ondansetron 4 mg IV q 6 hrs prn nausea vomiting (N&V) since it is not uncommon post-op for the patient to have N&V. The rate of LR is a little high for such a small patient and could cause electrolyte imbalances. The nurse may also inquire about the oncologist being on the case and ask if the surgeon has discussed reconstruction with the patient yet. She may also want to ask about dressing change orders.

Natasha sleeps through the night with no complaints of pain. Lab comes to draw the ordered labs and the CNA takes vital signs. See below.

CBC HGB 7.2 g/dl HCT 21.6%

BMP Sodium 130 mEq/L Potassium 6.0 mEq/L BUN 5 mg/dL

BP 84/46 SpO2 91% on Room Air HR 109 RR 22 bpm

What should the nurse do FIRST? Is the nurse concerned about the AM labs? AM vital signs? Why or why not?

• Check the dressing and drain for bleeding (assess the patient). The patient should also sit up and allow staff to check the bed for signs of bleeding. Reinforce the dressing as needed. Record output from the drain (or review documentation of all the night’s drain output). Labs and vital signs indicate she may be losing blood.

Check the dressing and drain for BLEEDING (assess the patient). The patient should also sit up and allow staff to check the bed for signs of bleeding. Reinforce the dressing as needed. Record output from the drain (or review documentation of all the night’s drain output). Labs and vital signs indicate she may be losing blood.

What orders does the nurse anticipate from the surgeon?

• The nurse should expect an order to transfuse blood for this patient. Also, dressing reinforcement or change instructions are needed in the case of saturation)

How should the nurse address Natasha’s declaration? What alerts the nurse to a possible complication?

• First, the complication is that “Kingdom Hall” is the site of worship for Jehovah’s Witnesses. They do not accept ANY blood product, not even in emergencies. It is vital the nurse determines the patient’s affiliation and religious exceptions for medical care before moving forward. Next, employ therapeutic communication to elicit more details about Natasha’s concerns. Say things like, “tell me why you think you’re not attractive?” She may discuss reconstruction options or ask the patient to write down specific questions about this option to ask the provider later. Ask about getting family in to provide support. Seek information to give the patient about support groups and other resources available (as appropriate, ie. prosthetics, special undergarments/accessories, etc)

The surgeon orders 1 unit packed red blood cells to be infused. The nurse then goes to the patient to ask about religious affiliation and to discuss the doctor’s order. After verifying that Natasha is not a practicing Jehovah’s Witness, the nurse proceeds to prepare the transfusion.

What is required to administer blood or blood products?

• First, the patient’s CONSENT is required to give blood products. The nurse must also prepare to stay with the patient for at least the first 15 minutes of the transfusion taking a baseline set of V/S prior to infusion. Then, V/S per protocol (frequent). Education is also required. The patient should report feeling flushed, back or flank pain, shortness of breath, chest pain, chills, itching, hives. Normal saline ONLY for infusion setup and flushing: size IV 20g or higher. Always defer infusion time limits to “per policy” because this can differ vastly

How should the nurse respond to this question?

• Planning for post-op cancer treatment should have begun prior to the surgery. Ask the patient if she has discussed plans with her oncologist. Refer to any specialist documentation to see if this is mentioned. Remind the patient of the specialist’s assessment and planning information. Reinforce that testing of the tissue may change the course of treatment as well. Provide education AS PER THE PATIENT’S STATED PREFERENCE and/or resources based on what the plan includes (ie. chemotherapy, radiation, further surgery. Continually assess and reassess patient understanding. Include family and/or support with the patient’s approval.

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View the full transcript, nursing case studies.

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

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Breast Cancer Case

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Diet quality indices are associated with breast cancer by molecular subtypes in Mexican women

• Original Contribution
• Published: 26 September 2024

Cite this article

• Brianda Ioanna Armenta-Guirado   ORCID: orcid.org/0000-0003-2373-4501 1 ,
• Ángel Mérida-Ortega   ORCID: orcid.org/0000-0001-5195-5163 2 ,
• Lizbeth López-Carrillo   ORCID: orcid.org/0000-0002-3245-8337 2 &
• Edgar Denova-Gutiérrez   ORCID: orcid.org/0000-0001-9671-9682 3  

Inconclusive epidemiological evidence suggests that diet quality indices may influence breast cancer (BC) risk; however, the evidence does not consider the molecular expression of this cancer.

We aimed to evaluate if diet quality is related to molecular subtypes of BC, in women residing in Northern Mexico.

This is a secondary analysis of 1,045 incident cases and 1,030 population controls from a previous case-control study, conducted between 2007 and 2011 in Northern Mexico. Information about the expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor 2 (HER2) was obtained from medical records to classify BC as luminal (ER + and/or PR+/HER2–), HER2+ (ER+/–and/or PR+/–/HER2+), or triple-negative (TN) (ER– and PR–/HER2–) cases. Food consumption was assessed with a semi-quantitative food frequency questionnaire. Diet quality was evaluated using the Mexican Diet Quality Index (MxDQI) and the Mexican Alternative Healthy Eating Index (MxAHEI). We used unconditional logistic regression models to estimate the association between Mexican diet quality indices and BC molecular subtypes.

The MxDQI was related to lower odds of BC (OR T3vsT1 =0.24; 95%CI: 0.18, 0.31). Similarly, MxAHEI was negatively associated with BC (OR T3vsT1 =0.43; 95%CI: 0.34, 0.54). The associations of both indices remained significant in the ER + and ER- tumors, and in the BC luminal and HER2 + molecular subtypes, except in the TN molecular subtype for MxAHEI, which was not statistically significant.

Conclusions

Our findings showed that MxDQI and MxAHEI were negatively associated with BC risk regardless of its molecular subtype.

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This work was supported by the National Council for Science and Technology (CONACyT by its acronym in Spanish)-Sector Fund for Research in Health and Social Security (FOSISS) (SALUD-2005-C02-14373).

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Brianda Ioanna Armenta-Guirado

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Ángel Mérida-Ortega & Lizbeth López-Carrillo

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Conceptualization: [Brianda Ioanna Armenta-Guirado, Edgar Denova-Gutiérrez, Lizbeth López-Carrillo, and Ángel Mérida-Ortega]; Methodology: [Brianda Ioanna Armenta-Guirado, Edgar Denova-Gutiérrez, Lizbeth López-Carrillo, and Ángel Mérida-Ortega]; Formal analysis: [Brianda Ioanna Armenta-Guirado, Edgar Denova-Gutiérrez, and Ángel Mérida-Ortega]; Resources: [Lizbeth López-Carrillo]; Data curation: [Brianda Ioanna Armenta-Guirado, Edgar Denova-Gutiérrez, and Ángel Mérida-Ortega]; Writing original draft preparation: [Brianda Ioanna Armenta-Guirado, Edgar Denova-Gutiérrez, Lizbeth López-Carrillo, and Ángel Mérida-Ortega]; Writing review and editing: [Brianda Ioanna Armenta-Guirado, Edgar Denova-Gutiérrez, Lizbeth López-Carrillo, and Ángel Mérida-Ortega]. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Edgar Denova-Gutiérrez .

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This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics, Research, and Biosafety Committee of the National Institute of Public Health (Date: May 21, 2007/No. CB-090).

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Brianda I. Armenta-Guirado: no conflicts of interest; Ángel Mérida-Ortega: no conflicts of interest; Lizbeth López-Carrillo: no conflicts of interest and Edgar Denova-Gutiérrez: no conflicts of interest. The authors have no relevant financial or non-financial interests to disclose.

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Armenta-Guirado, B.I., Mérida-Ortega, Á., López-Carrillo, L. et al. Diet quality indices are associated with breast cancer by molecular subtypes in Mexican women. Eur J Nutr (2024). https://doi.org/10.1007/s00394-024-03502-y

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Received : 30 October 2023

Accepted : 09 September 2024

Published : 26 September 2024

DOI : https://doi.org/10.1007/s00394-024-03502-y

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