Melissa A. Grier, MSN, APRN, ACNS-BC
When we think about breast cancer, what often comes to mind is a localized lump found on a mammogram or breast self-exam. We might also consider lymph node involvement and metastasis to other areas in the body. These more common manifestations of breast cancer are present in 8 out of 10 patients with breast cancer. However, as frontline nurses, we may encounter rare types of breast cancers that present differently. Inflammatory breast cancer is one of these.
What is it?
Inflammatory breast cancer is a rare, aggressive invasive ductal carcinoma that accounts for 1% to 5% of breast cancers diagnosed in the United States. It originates in the cells that line the milk ducts of the breast.
Who does it affect?
Inflammatory breast cancer is more common among African American women. It’s often diagnosed at a younger age and is more prevalent among obese women. It can occur in men, but usually presents later in life than it does in women.
What are the symptoms?
Erythema and edema over one-third or more of the affected breast are the most common presenting symptoms, which is why inflammatory breast cancer is often initially diagnosed as mastitis or some other type of infection. Ridges or pits may be present in the skin over the breast. This symptom, known as peau d’orange
because of the resemblance to an orange peel, is caused by buildup of fluid beneath the skin resulting from blockage of lymph vessels. Other symptoms include an inverted nipple, rapid engorgement of the affected breast, burning or tenderness, and the sensation of heaviness in the affected breast.
How is it diagnosed?
Advanced disease (stage III or later) is often present at the time of diagnosis due to the aggressive nature of inflammatory breast cancer. Because of edema caused by buildup of lymphatic fluid, palpation of a lump may be difficult or impossible. Most women with inflammatory breast cancer also have very dense breast tissue, making detection via mammography more difficult. In order to prevent delayed diagnosis and ensure that the best course of treatment is selected, the following minimum criteria have been outlined:
- Rapid onset of erythema, edema, and peau d’orange appearance with or without a palpable lump
- Symptoms present for less than 6 months
- At least one-third of the breast affected by erythema
- Initial biopsy results reveal invasive carcinoma
Ultrasound of the breast and nearby lymph nodes may be performed to aid in diagnosis, especially if mammography is inconclusive. A PET or CT scan might also be performed to rule out metastatic disease.
Further diagnostic testing is often performed to determine whether the cancer cells have hormone receptors (estrogen and progesterone) or if the cancer is HER2-positive, which will help guide treatment.
How is it treated?
A multimodal approach is usually necessary, which includes neoadjuvant chemotherapy, surgical resection of the tumor, radiation therapy, and adjuvant chemotherapy.
Treatment will likely include at least 6 cycles of anthracycline and taxane drugs administered over 4 to 6 months prior to surgery. If disease progression is noted during chemotherapy treatment, surgery may be moved forward, followed by adjuvant chemotherapy.
If the tumor is HER2 positive, trastuzumab (Herceptin) may be used before and after surgery to target the protein.
The presence of hormone receptors within the cancer cells influence treatment options. Tamoxifen can be used to prevent estrogen from binding to the cancer’s estrogen receptors. Aromatase inhibitors prevent the body from producing estrogen, slowing or completely stopping growth of the tumor.
A modified radical mastectomy is often necessary for patients with inflammatory breast cancer. The entire affected breast and most or all of the lymph nodes beneath the adjacent arm are removed. Smaller chest muscles (pectoralis minor) and the lining over chest muscles may also need to be removed.
After surgical resection, radiation therapy is initiated. Patients may be eager to pursue reconstruction, but it’s recommended that they wait until radiation is complete to prevent complications and allow healing of tissue to take place.
In order to prevent recurrence of the cancer, systemic chemotherapy, targeted therapy, and/or hormone therapy may be prescribed following surgery.
Where can I learn more about inflammatory breast cancer?
Melissa Grier is a clinical nurse specialist at Via Christi Health in Wichita, Kansas, where she supports the Via Christi Cancer Institute and the nurse residency program.