Paget Disease of the Breast: What Oncology Nurses Should Know About Recognition, Diagnosis, and Management

Paget disease of the breast is a rare manifestation of breast cancer that presents unique diagnostic and care challenges in oncology practice. For oncology nurses, early recognition of characteristic skin changes and coordination of multidisciplinary care are critical to optimizing outcomes. Although the condition accounts for approximately 1% to 4% of breast cancer cases, it is frequently associated with underlying ductal carcinoma in situ (DCIS) or invasive carcinoma, underscoring the importance of thorough evaluation and patient education.

Overview of Paget disease of the breast in oncology practice

Paget disease of the breast is characterized by malignant epithelial cells (Paget cells) infiltrating the epidermis of the nipple-areolar complex. The disease typically originates in the lactiferous ducts and extends outward to the nipple surface. In most cases, an underlying malignancy is present within the same breast.

From a nursing perspective, understanding this association is essential when reinforcing the need for comprehensive imaging and biopsy, even when presenting symptoms appear dermatologic in nature. Early-stage disease is highly treatable, and prompt identification can significantly affect prognosis.

Recognizing key symptoms and clinical presentation

Patients with Paget disease often initially present with nonspecific dermatologic symptoms, which may delay diagnosis. Oncology nurses are frequently positioned to identify concerning patterns during patient intake or follow-up assessments.

Common presenting signs include:

• Erythema of the nipple and areola
• Scaling, crusting, or flaking skin
• Pruritus or tingling sensation
• Increased nipple sensitivity
• Serous or bloody nipple discharge

These symptoms are often mistaken for benign conditions such as eczema or dermatitis. A key clinical distinction is that Paget disease typically affects only one breast and may not respond to topical therapies.

Diagnostic workup: biopsy and imaging essentials

A structured diagnostic approach is required:

• Physical Examination: Assessment includes inspection of the nipple-areolar complex and palpation for underlying masses or lymphadenopathy. Nurses play a role in documenting skin changes and reporting progression.
• Biopsy: A punch or wedge biopsy of the nipple is the gold standard for diagnosis. Identification of Paget cells confirms malignancy.
• Imaging:
  • Mammography and ultrasound are first-line modalities to evaluate for underlying tumors.
  • Breast MRI may be indicated when initial imaging is inconclusive or to further define disease extent.

Nurses should prepare patients for these procedures, address anxiety, and reinforce the importance of completing the full diagnostic evaluation.

Surgical management and treatment planning

Management of Paget disease is guided by the presence and extent of underlying malignancy. Oncology nurses are integral in patient education, perioperative care, and monitoring treatment-related toxicities.

Surgery is the cornerstone of treatment:

• Breast-Conserving Surgery (Lumpectomy): Involves excision of the nipple-areolar complex and surrounding tissue. Typically followed by radiation therapy.
• Mastectomy: Indicated for more extensive disease or when breast conservation is not feasible. May include sentinel lymph node biopsy or axillary staging.

Nursing responsibilities include preoperative education, postoperative wound care, and monitoring for complications such as infection, seroma, or lymphedema.

Adjuvant therapies: radiation, chemotherapy, and hormone therapy

Treatment may include:

• Radiation Therapy: Common following breast-conserving surgery. Nurses should assess skin integrity and provide guidance on managing radiation dermatitis.
• Chemotherapy: Considered for invasive or node-positive disease. Monitoring for myelosuppression, gastrointestinal toxicities, and infection risk is essential.
• Hormone Therapy: Used for hormone receptor–positive disease. Nurses should educate patients about adherence and manage menopausal-like side effects.

Managing treatment-related side effects in clinical practice

Understanding and proactively managing adverse effects can improve patient quality of life and treatment adherence.

• Post-surgical effects: Pain, edema, altered sensation, and body image concerns. Nursing interventions include pain management, patient education, and referral to support services when needed.
• Radiation toxicities: Erythema, desquamation, and fatigue. Skin care protocols and energy conservation strategies should be reinforced.
• Systemic therapy effects:
  • Chemotherapy: Alopecia, nausea, neutropenia
  • Hormone therapy: Hot flashes, mood changes, arthralgia

Oncology nurses should encourage prompt reporting of symptoms and coordinate supportive care interventions.

Patient education and nursing considerations across the care continuum

A diagnosis of Paget disease of the breast can be distressing, particularly given its visible presentation. Oncology nurses play a central role in patient counseling and shared decision-making.

Key discussion points include:

• The likelihood of an underlying breast malignancy
• Surgical options and expected outcomes
• Impact of treatment on daily functioning and long-term health
• Importance of follow-up care and surveillance

Encouraging patients to ask questions and actively participate in their care planning can enhance engagement and satisfaction.