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Capstone Case Study: Breast Cancer
Nayaris Reyes
Florida National University
Advanced Primary Care of Family
Professor: Jorge Brito
November 17, 2022
Capstone Case Study: Breast Cancer
Breast cancer is one of the most prevalent cancers that affect women. Among parous women, research suggests that breastfeeding could reduce the chances of being affected by this type of cancer. According to Anstey et al. (2017), breast cancer is the most commonly diagnosed cancer and leads to most death cases caused by cancer among women. Breastfeeding could reduce the chances of breast cancer by protecting breastfeeding mothers from some invasive breast cancer types (Anstey et al., 2017). However, there is a significant amount of evidence that suggests that the reduction of chances of breast cancer among breastfeeding women highly depends on various factors with African American women being more affected by this cancer than Caucasian women; thus, studies may have varying results.
Women who breastfeed for more than twelve months are less likely to get breast cancer as the chances of being affected reduce by 26% (Breast Cancer Association Consortium, 2021). Breastfeeding is associated with hormonal changes and reduces the exposure to hormones such as estrogen to parous women that increase breast cancer growth. During breastfeeding, women shed breast tissue, and in the process remove damaged DNA reducing the rate of developing breast cancer. The same studies reveal that few women (3%) develop breast cancer when breastfeeding while most women who develop cancer are over forty years with 5% of breast cancer patients being women below forty (Breast Cancer Association Consortium, 2021).
PICOT Question
The PICOT question is: In parous women (P), how does breastfeeding (I) compared to not breastfeeding (C) affect the risk of developing breast cancer (O) in 2 years (T)? The population in this study is parous women, that is, those who have given birth. The intervention is breastfeeding, which is intended to reduce the vulnerability of developing breast cancer in parous women, while the comparison is parous women who do not breastfeed. The outcome of the intervention is the reduction or decrease of breast cancer among the parous women who have chosen to breastfeed their babies and the time taken for the intervention is breastfeeding for two years. The PICOT question does not consider the breast cancer risk in nulliparous women as these women cannot breastfeed when they have not given birth, therefore, cannot produce milk.
The Vulnerable Population
Although all women can be affected by breast cancer, parous women over the age of forty years are more vulnerable to this type of cancer. According to research conducted by the Breast Cancer Association Consortium in 2021, one in every eight women develops breast cancer once in their lifetime. Research shows that only 4.7% of cancers affecting breasts are found in women below forty with over 70% of breast cancers being diagnosed in women above fifty years (Heer et al., 2020). While research shows that Caucasian women are more likely to be diagnosed with this type of cancer, women of color, especially African American women are more likely to die from this type of cancer, which makes race a significant risk factor for breast cancer (Yedjou et al., 2019).
Breast cancer can be contributed by various risk factors with some being controllable and others being uncontrollable. Some of the breast cancer risk factors that can be controlled or changed include obesity, hormone replacement therapy, alcohol consumption, physical activity, breastfeeding, contraceptives, smoking, diet, and environmental pollutants among others. Risk factors associated with breast cancer that cannot be changed and are uncontrollable include breast density, family history, radiation, genetics, race, age, personal history, age of menstruation, age of first birth, diethylstilboestrol (DES) exposure, serum oestradiol level, atypical hyperplasia and age at menopause among others (Xiao et al., 2019).
Literature Review
According to Stordal (2022), women in developed countries have a 15% likelihood of developing cancer because they have children at a later age and have few babies. However, this risk is reduced by 4.3% for every 12 months they breastfeed and further by 7.0 % for each birth (Stordal, 2022). The authors in this article state that breastfeeding reduces BCRA1 mutations and triple-negative breast cancer due to pregnancy changes such as cellular differentiation and RNA processing. According to the researchers, the longer women breastfeed, the greater the reduction in their vulnerability.
Reducing postmenopausal hormone therapy is another intervention that is associated with a reduced risk of breast cancer. Rozenberg et al. (2021) state that a combination of hormonal therapy increases the chances of breast cancer while limiting the hormonal therapy reduces the risk. The article states that nonhormonal therapies and medications reduce the chances of this type of cancer. According to the researchers, hormonal therapy through birth control pills and other contraceptives releases hormones such as estrogen that are associated with breast cancer. Research done in the recent past shows that women who use hormonal contraceptives increase the risk of breast cancer. The authors propose the use of preventive endocrine medications that inhibit the production of excess estrogen that increases individuals’ vulnerability to breast cancer. The intervention laid out in this article says that since hormonal therapy is important in regulating conception and menstruation among other functions, it should not be completely avoided but should be used for the shortest time possible.
The risk of breast cancer can be reduced through pharmacological interventions. Breast cancer can be prevented through the use of tamoxifen and raloxifene. These are drugs approved by the food and drug agency (FDA) as safe to reduce the vulnerability to breast cancer in women that are more likely to be affected by this cancer due to family history or other risk factors (Yao et al., 2019). Although some researchers find the use of pharmacological interventions such as tamoxifen and raloxifene as unhealthy practices, these drugs reduce the chances of breast cancer in women over forty years and those with a family history of this type of cancer. However, these drugs have side effects and cannot be used by every woman and this is the reason why most researchers discourage using these drugs to reduce the risk of breast cancer. It is advisable for women considering using these drugs to reduce the vulnerability to this cancer to consult a physician before they use them.
According to Dimou et al. (2019), women who breastfeed for more than 12 months are 45% less susceptible to breast cancer when compared to parous women who choose not to breastfeed. This is because the longer a parous woman breastfeeds, the more the breastfeeding has a protective effect against breast cancer. According to the authors, breastfeeding also offsets the increased vulnerability to breast cancer as milk-delivery systems protect the women from precancerous cells especially in women who have several children or for a longer time. The authors suggest that the scientific evidence that shows that breastfeeding reduces the risk of cancer is growing significantly. According to the article, the menstrual cycle returns more often to parous breastfeeding women compared to those who do not breastfeed therefore reducing the effects of prolonged exposure to estrogen.
Bilateral Risk-Reducing Mastectomy (BRRM) is a preventive intervention that reduces the risk of breast cancer in women who are at high risk of this cancer. According to Thorat and Balasubramanian (2020), women with a family history of breast cancer are likely carriers of BRCA mutations (BCRA1 and BCRA2 gene carriers) and are at a high risk of developing breast cancer. BRRM helps reduce the risk of breast cancer in these women by developing new and stronger preventive agents for the breasts of these women. According to the authors, BRRM reduces individuals’ vulnerability to breast cancer by 45% when taken for four years (Thorat & Balasubramanian, 2020). This intervention involves removing one or both breasts as a way of protecting women at high risk from developing this cancer due to the presence of BCRA mutations in their body, a personal history of breast cancer, or a family history with more than one close relative developing this type of cancer.
Qiu et al. (2022) reviewed published literature on the association between breastfeeding and breast cancer. Although the researchers concluded that there is limited evidence that shows the relationship between breastfeeding and the risk of breast cancer, there were some studies that showed that there is a reduced number of breast cancer cases in parous women who breastfeed. The chances of developing breast cancer in parous women is reduced by the differentiation of breast cells as they are modified to produce milk after giving birth. This cell differentiation means that few breast cells and tissues are vulnerable to estrogen and other carcinogenic agents during breastfeeding, therefore, reducing the time these women are exposed to estrogen which is associated with breast cancer.
Strengths and Weaknesses of the Articles
The strength of Stordal (2020) is that the article adequate statistics that support the conclusion that breastfeeding impacts the vulnerability to breast cancer, but fails to sufficiently provide evidence how breastfeeding reduces this risk. Rozenberg et al. (2021) explain the impact of hormonal therapy on the risk of breast cancer but fails to provide nonhormonal therapies that can be used by parous women instead. The strength of Yao et al. (2019) article is that it offers an alternative to breastfeeding to lower the women’s vulnerability to breast cancer in women, but fails to point out the side effects of tamoxifen and ralofexene drugs. Dimou et al. (2019) supported their findings with statistics and percentages of the risk of breast cancer in women in developed countries but fail to compare the findings with statistics of breast cancer cases in developing countries. The strength of Thorat and Balasubramanian (2020) is that it focuses on gene mutations and the type of breast cancer they cause. However, this article focuses on genes and family history risk factors but ignores other risk factors. Lastly, the strength of Qui et al. (2022) is that it points out the link between breastfeeding with the risk of breast cancer. However, this source is limited, in that, it lacks statistics and figures to support breastfeeding intervention.
Proposal
In parous women, breastfeeding can reduce the risk of breast cancer due to the constant shedding of breast tissue that removes damaged DNA in the breast that causes abnormal cell growth. This intervention only targets parous women, as nulliparous women cannot breastfeed. This intervention is very effective in parous women who have their children while young. This intervention aims to remove damaged DNA in the breast and regulate estrogen action in the breast of breastfeeding women as low exposure to this hormone reduces the risk of this cancer (Breast Cancer Association Consortium, 2021). This intervention recommends that women breast their babies for at least two years as it benefits both the mother and the baby with the former reducing the risk of breast cancer and the latter developing a strong immune system.
An advanced nursing practitioner have the skills to coordinate the individuals involved in implementing the intervention. They can encourage parous women to join a breastfeeding support group to ensure the intervention is successful. Some of the resources that can be used in implementing this intervention include fact sheets, toolkits, reports, and published documents that support breastfeeding (Basree et al., 2019). The nurse can target women with low breastfeeding self-efficacy and the intervention should be introduced in the antenatal stage to ensure the mother is ready to breastfeed after giving birth. The nurse can also consider a follow-up to offer support and ensure that parous women breastfeed exclusively for six months and up to two years even after introducing food. The intervention should be implemented for two years after giving birth to ensure that it is effective.
References
Andò, S., Gelsomino, L., Panza, S., Giordano, C., Bonofiglio, D., Barone, I., & Catalano, S. (2019). Obesity, leptin and breast cancer: epidemiological evidence and proposed mechanisms. Cancers, 11(1), 62.
Anstey, E. H., Shoemaker, M. L., Barrera, C. M., O’Neil, M. E., Verma, A. B., & Holman, D. M. (2017). Breastfeeding and breast cancer risk reduction: Implications for black mothers. American Journal of Preventive Medicine, 53(3), S40-S46. https://doi.org/
Basree, M. M., Shinde, N., Koivisto, C., Cuitino, M., Kladney, R., Zhang, J., … & Ramaswamy, B. (2019). Abrupt involution induces inflammation, estrogenic signaling, and hyperplasia linking lack of breastfeeding with increased risk of breast cancer. Breast Cancer Research, 21(1), 18. https://doi.org/10.1186/s13058-019-1163-7
Breast Cancer Association Consortium. (2021). Breast cancer risk genes—association analysis in more than 113,000 women. New England Journal of Medicine, 384(5), 428-439.
Dimou, S., Mamakou, A., Konstantaki, E., & Spanou, M. (2019). The contribution of breastfeeding to the prevention of breast cancer. European Journal of Midwifery, 3(November).
Heer, E., Harper, A., Escandor, N., Sung, H., McCormack, V., & Fidler-Benaoudia, M. M. (2020). Global burden and trends in premenopausal and postmenopausal breast cancer: a population-based study. The Lancet Global Health, 8(8), e1027-e1037. https://doi.org/10.1016/S2214-109X(20)30215-1
Qiu, R., Zhong, Y., Hu, M., & Wu, B. (2022). Breastfeeding and reduced risk of breast cancer: a systematic review and meta-analysis. Computational and Mathematical Methods in Medicine, 2022.
Rozenberg, S., Di Pietrantonio, V., Vandromme, J., & Gilles, C. (2021). Menopausal hormone therapy and breast cancer risk. Best Practice & Research Clinical Endocrinology & Metabolism, 35(6), 101577. https://doi.org/
Stordal, B. (2022). Breastfeeding reduces the risk of breast cancer: A call for action in high‐income countries with low rates of breastfeeding. Cancer Medicine. https://doi.org/
Thorat, M. A., & Balasubramanian, R. (2020). Breast cancer prevention in high-risk women. Best Practice & Research Clinical Obstetrics & Gynaecology, 65, 18-31. https://doi.org/10.1016/j.bpobgyn.2019.11.006
Yao, J., Deng, K., Huang, J., Zeng, R., & Zuo, J. (2020). Progress in the understanding of the mechanism of tamoxifen resistance in breast cancer. Frontiers in Pharmacology, 11, 592912.
Yedjou, C. G., Sims, J. N., Miele, L., Noubissi, F., Lowe, L., Fonseca, D. D., … & Tchounwou, P. B. (2019). Health and racial disparity in breast cancer. Breast Cancer Metastasis and Drug Resistance, 31-49.
