SY 2020-2021

COLLEGE OF NURSING
Silliman University
Dumaguete City

RESOURCE UNIT ON
BREAST CANCER

Presented to:
Asst. Prof. Osel Sherwin Y. Melad

Prepared by:
Fleischer, Kiara Marie M.
Guarin, Sherika Mariz M.

Teaching Date: ​October 17, 2020

Venue​: Google Meet via Video Conference
Topic: ​Breast Cancer
Time Allotment:​ 30 minutes
Topic Description: ​This topic provides an understanding of Breast Cancer. It emphasizes on its description, types, risk factors, pathophysiology, clinical manifestations, complications, grading
and staging, nursing diagnoses, and medical and nursing management/interventions.
Central Objective: ​At the end of the discussion, given the topic on Breast Cancer, the learners will satisfactorily demonstrate safe, effective, appropriate, and holistic care utilizing the nursing
process.

Specific Objectives Content TA T-L Activities Evaluation Method

At the end of this 30-minute 30 minutes Lecture-discussion Asking of questions

lecture-discussion, the with the use of a during
learners will be able to Concept Map lecture-discussion
correctly: BREAST CANCER
1. Define what is breast 1. Description
cancer. ➔ It refers to a group of malignant diseases that commonly occur in the female breast
and infrequently in the male breast.
➔ It is uncontrolled growth of epithelial cells in the breast. Also called breast carcinoma
and is the 2nd leading cause of cancer deaths in women after lung cancer (Osmosis,
2019).
➔ Breast cancer is the most common cancer in the Philippines, occurring in 16% of
50,000 cases diagnosed with cancer. It is most prevalent in the 35-40 year old age
group of Filipino women.

2. Identify the different 2. Types Of Breast Cancer

types of breast cancer. a. In situ carcinoma​: Once mutation occurs, the affected cell, especially epithelial
cell, begins to grow & replicate out of control, forming a tumor called in-situ
carcinoma. It is initially localized in the basement membrane of Alveoli.
i. ​Ductal Carcinoma in-situ (DCIS) – The tumor cells grow from the wall of the
ducts into Lumen. It rarely crosses basement membranes.
i.a. Paget’s Disease of the nipple – Cancer cells can migrate along
lactiferous duct, through pore, into the skin. The cancer cells release a
mobility factor, which helps them break into and settle in between the
squamous epithelial cells. As cancer cells move into the epithelium, there’s
inflammation which brings extracellular fluid out of through breaks in the
skin. This fluid then dries and forms crusts over the skin's surface.
ii. ​Lobular carcinoma in-situ (LCIS) – Clusters of tumor cells grow within the
lobules, without invading the ducts, causing the affected alveoli to enlarge. Unlike
DCIS, over time LCIS doesn’t cross the basement membrane to form invasive
 lobular carcinoma. Just like healthy alveolar cells, some breast cancer cells have
hormone receptors that allow them to grow in the presence of the hormones.

b. Invasive breast cancer​: Cancer metastasizes to other parts of the body through
the bloodstream and lymph nodes. Also known as infiltrating breast cancer, this
type of breast cancer spreads to tissue around the breast or other regions of the
body. IDC (invasive ductal carcinoma) makes up 70% of all invasive breast cancer
types and begins in the milk ducts.
i. ​Invasive lobular carcinoma (ILC), sometimes called infiltrating lobular
carcinoma, is the second most common type of breast cancer after invasive ductal
carcinoma (cancer that begins in the milk-carrying ducts and spreads beyond it).
ii. ​Invasive ductal carcinoma (IDC)​, sometimes called infiltrating ductal
carcinoma, is the most common type of breast cancer. About 80% of all breast
cancers are invasive ductal carcinomas. Invasive means that the cancer has
“invaded” or spread to the surrounding breast tissues. Ductal means that the cancer
began in the milk ducts, which are the “pipes” that carry milk from the
milk-producing lobules to the nipple.
iii. ​Triple Negative Breast Cancer (TNBC): Usually invasive, this type of breast
cancer accounts for 10 to 20% of all breast cancers and originates from the breast
ducts. These types of cancer cells do not contain receptors for estrogen,
progesterone or a protein called HER2 as do normal breast cells. On the other
hand, 20 to 30% of breast cancer cancers are characterized by the over presence of
HER2 receptors responsible for stimulating cell growth.

c. Others
i. ​Pregnancy-associated breast cancer (PABC) is defined as breast cancers
diagnosed up to 5 years after a completed pregnancy; however, risk may persist for
a decade.
ii. ​Inflammatory Breast Cancer (IBC): IBC results in the blockage of lymph
vessels in the skin of the breast from infected soft tissue. The description
“inflammatory” is associated with the appearance of itchy, red, tender, warm and
firm breasts resulting from the accumulation of white blood cells and stimulated
blood flow in the skin.

3. List the risk factors that 3. Risk Factors

can possibly put an Predisposing factors:
individual at risk for ➢ Age.​ Incidence of breast cancer in women under 25 years of age is very low and
having breast cancer. increases gradually until age 60. After the age of 60, the incidence increases
 dramatically.
➢ Gender​. Women are more at risk for breast cancer than males. They account for
99% of breast cancer cases.
➢ Genetic Link​. Mutations occur in BRCA1 and/or BRCA2 genes. ​BRCA1 is a gene
located on the 17q21 chromosome. This mutation is associated with nearly half of
the early-onset breast cancers. ​BRCA2 ​is a gene located on the 13q12-13
chromosome. This mutation has a lower incidence of early-onset of breast cancers
(35%).
➢ Race​. Blacks have higher incidence up to age 40 yr; whites have higher incidence
after age 40
➢ Early menarche (before 12 years old) and ​Late menopause (after age 55). Long
menstrual history increases risks of breast cancer.
➢ Personal history: breast cancer, colon cancer, endometrial cancer, ovarian cancer.
This significantly increases risk of breast cancer, risk of cancer in other breast, and
recurrence.
➢ Family history​.
A family member with:
➔ Ovarian cancer
➔ Breast cancer in first-degree relative, particularly when premenopausal or
had bilateral breast cancer
➔ Gene mutations of BRCA1 or BRCA2. Both are tumor suppressor genes
who are located on chromosome 17 (BRCA1 and chromosome 11
(BRCA2) (Casanova, 2019).
➔ P53 (Li-Fraumeni syndrome)
➢ Predisposing risk factors for breast cancer in males: states of hyperestrogenism,
family history of breast cancer, and radiation exposure.

Precipitating Factors:
➢ Sedentary lifestyle
➢ Dietary fat intake
➢ Previous medical history
➔ Benign breast disease with atypical epithelial hyperplasia, lobular
carcinoma in situ. Atypical changes in breast biopsy increase the risk of
breast cancer.
➔ Moderate or florid mammary hyperplasia
➔ Mammary papilloma
➢ Estrogen therapy
➔ The use of combined hormone therapy such as estrogen and progesterone
 increases the risk of breast cancer in women.
➔ The use of estrogen therapy alone for longer than 10 years (for women with
prior hysterectomy)
➢ Nulliparity or first full-term pregnancy after 30 years old​. Prolonged exposure to
unopposed estrogen increases risk for breast cancer.
➢ Exposure to ionizing radiation. ​Radiation damages DNA (e.g. prior treatment for
Hodgkin’s lymphoma)
➢ Dietary fat intake
➢ Alcohol consumption​. Women who drink ≥1 alcoholic beverage per day have an
increased risk of breast cancer.
➢ Weight gain and obesity after menopause​. Fat cells store estrogen.

4. Analyze the 4. Pathophysiology

pathophysiology of According to (Hamolsky, 2014), the main components of the breast are lobules
breast cancer. (milk-producing glands) and ducts (milk passages that connect the lobules and the nipple).
In general, breast cancer arises from the epithelial lining of the ducts (ductal carcinoma) or
from the epithelium of the lobules (lobular carcinoma). Breast cancers may be in situ
(within the duct) or invasive (arising from the duct and invading through the wall of the
duct).
Metastatic breast cancer is breast cancer that has spread to other organs, with the most
common sites being bone, liver, lung, and brain. Cancer growth rates can range from slow
to rapid. Factors that affect cancer prognosis are tumor size, axillary node involvement
(the more nodes involved, the worse the prognosis), tumor differentiation, estrogen and
progesterone receptor status - , and human epidermal growth factor receptor 2 (HER-2)
status. HER-2 is a protein that helps regulate cell growth. It is overexpressed in about 25%
of patients with breast cancer.

Cells of glandular tissue have receptors for certain hormones like estrogen and
progesterone, which are released by the ovaries, and prolactin, which is released by the
pituitary gland. These hormones stimulate the alveolar cells to divide and increase in
number, which makes the lobule enlarge. Without these hormones, the glandular cells,
particularly the alveolar cells, can’t survive and undergo apoptosis, a programmed cell
death.
During the menstrual cycle, there’s an increase in estrogen and progesterone. Every cycle,
alveolar cells undergo division and apoptosis. Each time cells divide there’s a chance that
a genetic mutation will occur, which could lead to tumor formation. These are linked to
mutations in Tumor Suppressor Genes, such as Breast cancer gene: BRCA-1 & BRCA-2
and TP53, which normally slow down cell division or make cells die if they divide
 uncontrollably. In males, breast cancer is caused by inherited mutations in the BRCA-1 &
2 genes. Breast cancer is also linked to ERBB2 gene or HER-2 (Human Epidermal growth
factor receptor 2), which when activated, promotes the growth of cells.

5. Identify the clinical 5. Clinical Manifestations

manifestations of breast ● Lump or ​mammographic abnormality in the breast​. This is the most common
cancer and classify the symptom of breast cancer that occurs most often in the upper, outer quadrant of the
different stages and breast because it is where most of the glandular tissue is located.
grades of a breast cancer ● If ​palpable​, breast cancer is characteristically:
tumor. ○ Hard
○ Irregularly shaped
○ Poorly delineated
○ Nonmobile
○ Nontender
● Nipple discharges​: usually unilateral and may be clear or bloody
● Nipple retraction
● Peau d’orange​ due to the plugging of dermal lymphatics
● In large cancers:
○ Infiltration
○ Induration
○ Dimpling (pulling in) of the overlying skin

Tumor Staging and Grading

A complete diagnostic evaluation includes identifying the stage and grade of the tumor.
a. Staging. ​The most widely accepted staging method for breast cancer is the
American Joint Committee on Cancer’s TNM (Tumor, nodes, and metastasis)
system. This system uses tumor size (T), nodal involvement (N), and presence of
metastasis (M) to determine the stage of disease. The stage of a breast cancer
describes its size and the extent to which it has spread.
Stage 1 -​ ​Tumor is less than 2 cm in size
-​ ​No lymph node involvement
-​ ​No metastasis

Stage 2 (A)
-​ ​No evidence of tumor ranging to 5 cm
-​ ​No, or 1-3 axillary nodes and/or internal mammary nodes
-​ ​No metastasis
 (B)
-​ ​Ranging from 2 cm to greater than 5 cm
-​ ​No, or 1-3 axillary nodes and/or internal mammary nodes
-​ ​No metastasis

Stage 3 (A)
-​ No evidence of tumor ranging greater than 5 cm
​

-​ ​4-9 axillary nodes and/or internal mammary nodes

-​ ​No metastasis

(B)
-​ ​Any size greater than 5 cm with extension to chest wall or
skin
-​ ​4-9 axillary nodes and/or internal mammary nodes
-​ ​No metastasis
(C)
-​ ​Any size greater than 5 cm
-​ ​10 or more axillary nodes, internal mammary nodes, or
infraclavicular nodes
-​ ​No metastasis

Stage 4 -​ ​Any size greater than 5 cm

-​ ​Any type of nodal involvement
-​ ​With metastasis

b. Grading​. According to Johns Hopkins University (2020), the grade of a breast

cancer is a prognostic factor and is a representative of the “aggressive potential” of
the tumor.
● Grade 1 or low-grade - ​(well-differentiated) Looks most like normal breast
cells and growth is slow and well-organized pattern. Not that many cells are
dividing in making new cancer cells.
● Grade 2 or intermediate/moderate grade - ​(moderately differentiated) Do not
look like normal cells and growth and division is a little faster than normal.
● Grade 3 or high grade - ​(poorly differentiated) Looks very different from
normal cells and growth is quick and disorganized, irregular patterns, with
many dividing to make new cancer cells (Breast Cancer Organization, 2020).
6. Identify the
6. Complications
complication/s of breast
 cancer. According to (Hamolsky, 2014), ​Recurrence is the main complication of breast cancer. It
may be local or regional (skin or soft tissue near the mastectomy site, axillary or internal
mammary lymph nodes) or distant (most commonly involving bone, lung, brain, and
liver). However, metastatic disease can be found in any site in the body. Metastases
primarily occur through the lymphatics, usually those of the axilla. However, the cancer
can spread to other parts of the body without invading the axillary nodes even when the
primary breast tumor is small. Even in patients who do not have lymph node involvement
(node-negative breast), there is a possibility of distant metastasis.

7. Identify significant data 7. Assessment

from the assessment of a Physical Examination
client with breast cancer. - History of breast disorder
- Presence of nipple discharge, pain, rate of growth of the lump, breast asymmetry, and
correlation with the menstrual cycle should all be investigated.
- Size and location of the lump/s should be carefully documented
- Physical characteristics of the lesion: consistency, mobility, and shape should be
assessed
- If nipple discharge is present, note the color and consistency as well as whether it occurs
from one or both breasts.
- Subjective data:
○ Past health history (benign breast disease with atypical changes; previous unilateral
breast cancer; menstrual history; pregnancy history; previous endometrial, ovarian,
or colon cancer; hyperestrogenism, and testicular atrophy (in men))
○ Medications: use of hormones (especially postmenopausal hormone replacement
therapy and oral contraceptives, infertility treatments)
○ Surgery or other treatments: exposure to therapeutic radiation (e.g. Hodgkin’s
lymphoma or thyroid radiation)
- Abnormal Findings​: Solitary unilateral non-tender mass. Single focus in one area,
although it may be interspersed with other nodules. Solid, hard, dense and fixed
underlying tissues or skin as cancer becomes invasive. Borders are irregular and poorly
delineated. Grows constantly. Often, painless, although the person may have pain. Most
common in the upper quadrant. As cancer advances, signs include firm or hard irregular
axillary nodes; skin dimpling; nipple retraction, elevation, and discharge. (Jarvis, 2004)

8. Understand the different 8. Diagnostic Tests

diagnostics for breast Mammography i​ s a type of X-ray examination that detects breast cancers too small to feel
 cancer. (less than 1 cm). The American. Cancer Society recommends mammography every year
for women over 40 years old. However, some authorities suggest that yearly is too
frequent, and the U.S. Preventive Services Task Force on Breast Cancer Screening
recommends delaying mammography screening until age 50.

Diagnostic MRI scans ​seem to be preferable for at-risk women who carry a mutated
BRCA gene. Besides heightened monitoring, many women with the BRCA mutation are
opting to have their breasts and/or ovaries surgically removed as a preventive measure.
(Marieb & Hoehn, 2015). It may also be used as part of post-cancer breast diagnosis for
further evaluation of breast involvement.

Ultrasonography has come to play an important role in the evaluation of breast lesions. It
is useful in evaluating inconclusive mammographic findings, in evaluating the breasts of
young women and others with dense tissue, allowing better differentiation between a solid
and cystic mass, and in guiding tissue core-needle biopsies.

Fine-needle aspiration is useful in determining if a palpable lump is a simple cyst. The

procedure is performed in the office with or without the aid of local anesthesia. The
suspected mass is stabilized between two fingers of one hand and aspirated using a 22- to
24-gauge needle. Clear aspirated fluid does not need to undergo pathologic evaluation,
and the patient may return for a CBE within 4 to 6 months if the mass disappears. If it
reappears, the patient is managed with diagnostic mammography and ultrasonography.
Bloody aspirated fluid should be evaluated cytologically, and the patient should undergo
diagnostic mammography and ultrasonography.

Core-Needle Biopsy-​ In a core-needle biopsy, a large needle (14–16 gauge) is used to

obtain samples from larger, solid breast masses. Three to six samples of tissue
approximately 2 cm long are obtained and are evaluated for abnormal cells in relation to
the surrounding breast tissue taken in the sample.

9. Differentiate the 9. Medical Management

different types of Surgical Management
therapies/ medical and 1) Mastectomy is removal of all breast tissue and the nipple areolar complex with
pharmacological preservation of the pectoralis muscles (Casanova, 2019).
managements for breast Modified Radical Mastectomy​. It is used to treat invasive breast cancer which
cancer. involves the removal of breast tissue, including nipple-areola complex. In
addition, a portion of the axillary lymph nodes are also removed in axillary
 lymph node dissection (ALND).
Total Mastectomy​. This involves the removal of the breast and nipple-areola
complex but does not include axillary lymph node dissection (ALND).
2) Breast-conservation therapy. It is also known as ​lumpectomy ​or wide local
excision, BSC involves resection of the tumour along with a margin of tissue while
conserving the cosmetic appearance of the breast. Most breast surgeries are of this
type because (i) most tumours are locally invasive and (ii) large primary tumours
can be reduced in size by neoadjuvant chemotherapy prior to conservative surgery
(Chaudhry, Rossi, & Wong, 2018).
3) Quandratectomy.​ This procedure removes the quadrant of the breast in which the
cancer is located
4) Axillary Node Dissection. T ​ his procedure removes ipsilateral lymph nodes. Also
part of the modified radical mastectomy and the standard mastectomy.

Radiation Therapy
- It is used in conjunction with mastectomy for later stages of breast cancer and to
accompany lumpectomy and partial mastectomy for early stages of breast cancer.
Radiation is an essential component of lumpectomy. The combination of
lumpectomy and radiation yields outcomes that are equal to those of radical
mastectomy.
Nursing Management in Radiation Therapy
➔ Assessment. The nurse assesses the patient’s skin and oropharyngeal
mucosa regularly when radiation therapy is directed to these areas, and also
the nutritional status and general well-being should be assessed.
➔ Symptoms. If systemic symptoms, such as weakness and fatigue, occur, the
nurse explains that these symptoms are a result of the treatment and do not
represent deterioration or progression of the disease.
➔ Safety precautions. Safety precautions used in caring for a patient receiving
brachytherapy include assigning the patient to a private room, posting
appropriate notices about radiation safety precautions, having staff
members wear dosimeter badges, making sure that pregnant staff members
are not assigned to the patient’s care, prohibiting visits by children and
pregnant visitors, limiting visits from others to 30 minutes daily, and seeing
that visitors maintain a 6 foot distance from the radiation source.

Pharmacologic Management
5) Adjuvant (systemic) therapy is used in the treatment of all stages of breast cancer,
regardless of lymph node status. Adjuvant therapy includes chemotherapeutic
 drugs that kill cancer cells and hormonal therapies such as tamoxifen that act as
estrogen antagonists.

10. Demonstrate effective 10. Nursing Diagnoses and Nursing Management

and safe medical and General Nursing Management
nursing management of 1) Provide emotional support for the patient during diagnostic tests and treatment
clients with breast phases.
cancer. 2) Evaluate and be aware of painful effects of particular therapies (surgery, radiation,
chemotherapy, and biotherapy). Provide information to the patient and SO about
what to expect.
3) Be aware of barriers to cancer pain management related to the patient, as well as
the healthcare system.
4) Inform the patient and SO of the expected therapeutic effects and discuss
management of side effects.

Perioperative Nursing Diagnoses

❖ Knowledge Deficit r/t available options of treatment and surgery
1) The nurse should provide information to the client on recommendations and
treatment options before surgery or treatment is initiated.

❖ Fear or Anxiety related to the diagnosis of breast cancer

1) Assess the patient for stages of anxiety currently being experienced. Explain
process as appropriate.
2) Encourage verbalization of thoughts or concerns and accept expressions of
sadness, anger, rejection. Acknowledge normality of these feelings.
3) Reinforce teaching regarding disease process and treatments and provide
information as appropriate about dying. Be honest; do not give false hope while
providing emotional support.

Postoperative Nursing Diagnoses

❖ Acute pain related to surgical procedure
1) Determine pain history, e.g. location, frequency, duration, and intensity using pain
assessment scale.
2) Provide cutaneous stimulation, e.g. heat/cold, massage.
3) Encourage the use of relaxation techniques, e.g. music therapy, aromatherapy, etc.
4) Administer medications as indicated.
- Opioids, e.g. Codeine, morphine (Ms Contin), Oxycodone (OxyContin)
 - Acetaminophen (Tylenol), NSAIDs
- Corticosteroids, e.g. dexamethasone
- Anticonvulsants, e.g phenytoin (Dilantin)

❖ Risk for impaired skin integrity related to surgery or radiation therapy

1) Postoperatively, A pressure dressing is usually used initially. A drain, connected
to the gentle suction, prevents blood or serum collection in the operative space
after a modified radical mastectomy or axillary node dissection. The nurse needs to
instruct the client about emptying the drain and recording the amount of drainage.
The physician is notified if the drain becomes plugged, is dislodged, or shows
signs of infection or if frank bleeding develops.
2) Change dressing of client to avoid infection of surgery/provide wound care.
3) Teach the client to take care of his/her skin.

❖ Risk for injury r/t increased risk of infection and lymphedema secondary to axillary
node dissection
1) In the immediate postoperative period, the nurse should encourage patient to
perform arm exercises and should have the client elevate the arm to promote
lymphatic drainage and prevent infection.
2) Let the patient wear an elastic bandage or a custom fitted pressure gradient elastic
sleeve may also help be helpful.
3) Put up a sign on the client's bed warning that no blood pressure readings,
injections, intravenous catheterizations, or blood draws should be done on the arm
on the operative side because this can cause circulatory impairment or infections.

❖ Knowledge deficit r/t postoperative arm exercises and care, breast prosthesis,
chemotherapy and radiation therapy.
1) Encourage the patient to perform self-care activities such as feeding, combing hair,
washing face and other activities that use the arm, with care not to abduct the arm
or raise the arm or elbow above shoulder height until the drains are removed.
2) When Wound healing is established and access axillary drains are removed, assist
the patient to use ROM activities.

❖ Nutrition: less than body requirements r/t nausea, vomiting, and stomatitis secondary to
chemotherapy
1) The nurse must emphasize the importance of good nutrition. Encourage the patient
to eat a high-calorie, nutrient-rich diet, with adequate fluid intake.
2) Encourage use of supplements and frequent or smaller meals spaced throughout
 the day.
3) Weight and dietary patterns must be monitored.
4) Monitor daily food intake; have the patient keep a food diary as indicated.
5) Adjust diet before and immediately after treatment (clear, cool liquids, light or
bland foods, candied ginger, dry crackers, toast, carbonated drinks). Give liquids 1
hour before or 1 hour after meals.
6) Insert and maintain NG or feeding tube for enteral feedings, or central line for total
parenteral nutrition (TPN) if indicated.
7) Monitor I & O.
8) Monitor vital signs. Evaluate peripheral pulses, capillary refill.
9) Encourage increased fluid intake to 3000 mL per day as individually appropriate
or tolerated.

Breast Cancer Screening Guidelines

Screening guidelines for the early detection of breast cancer include the following:
➔ Yearly mammograms starting at age 40 and continuing for as long as a woman is
in good health. A controversial recommended change is that women at normal risk
for breast cancer should begin annual screening at age 50 and stop screening at age
75.
➔ Clinical breast examination (CBE) preferably at least every 3 years for women in
their 20s and 30s, and every year for women beginning at age 40.
➔ Women should report any breast changes promptly to their health care provider.
Breast self-examination (BSE) is an option for women starting at age 20.
➔ Women at increased risk (family history, genetic link, past breast cancer) should
talk with their health care provider about the benefits and limitations of starting
mammography screening earlier, having additional tests (e.g., breast ultrasound or
magnetic resonance imaging [MRI]), or having more frequent examinations.

References

Breast Cancer Organization. (2018). Types of Breast Cancer. Retrieved from https://www.breastcancer.org/symptoms/types/idc.

Breast Cancer Organization. (2020). Breast cancer cell grade. Retrieved from https://www.breastcancer.org/symptoms/diagnosis/cell_grade

Casanova, R., Chuang, A., Goepfert, A., Hueppchen, N., Weiss, P., Beckmann, C., … Smith, R. (2019). ​Obstetrics and Gynecology​ (8th ed.). Philadelphia, PA: Wolters Kluwer Health.

Chaudhry, S., Rossi, M., & Wong, E. (2018). ​Oncology: Breast Cancer​. Retrieved from ​http://www.pathophys.org/breast-cancer/
Hamolsky, D. (2014). Breast Disorders: Breast Cancer. In S. Lewis, S. Dirksen, M. Heitkemper, L. Bucher, & M. Harding, Medical-Surgical Nursing: Assessment and Management of
Clinical Problems (pp. 1243-1258). Missouri: Mosby, an imprint of Elsevier Inc.

Jarvis, C. (2004). Physical Examination & Health Assessment (4th ed.). Singapore: Saunders.

Johns Hopkins University. (2020). Staging & grade. Retrieved from https://pathology.jhu.edu/breast/staging-grade/

Marieb, E. N., & Hoehn, K. (2015). Human Anatomy & Physiology (10th ed.). Harlow, United Kingdom: Pearson Education Limited.

Osmosis. (2019). Breast cancer - causes, symptoms, diagnosis, treatment, pathology. Retrieved from ​https://www.youtube.com/watch?v=MiB1g1kbzXg&t=304s