Even when it is not possible to achieve a cure there are several palliative procedures which are useful in prolonging the patient's life and providing periods of time in which the patient is relatively free of pain and disability. For some, the period of remission is prolonged; for others the therapy may be less successful in terms of time but quite successful in terms of promoting increased comfort. The management of advanced breast cancer depends a great deal on the age and menopausal status of the patient. As stated previously many forms of palliative treatment may be employed. More than one type of therapy may be necessary for the same patient and it is important for the nurse to help the patient accept whatever therapy the physician has decided upon.

1. Surgical Procedures

It has been known for sometime that the growth of human breast cancer is dependent, at least in part, upon the endocrine secretions in the body. For this reason, the principal of removal of the various sources of hormones, in particular, estrogenic hormone, has been utilized in planning therapy.

a. Ovariectomy (oophorectomy)

Castration, or removal of the ovaries, may induce temporary regression of the disease by destroying the main source of estrogens. Remissions vary in length and tend to average about one year.

b. Adrenalectomy

The adrenal glands are known to be another source of estrogens in the body. Therefore, an adrenalectomy may be performed when the ovariectomy ceases to be effective. In some instances the adrenalectomy is combined with the ovariectomy, i.e., done at the same time.

Since the mechanism which helps the body react to stress has been interfered with in these patients (production of adrenalin in the adrenal glands) it is essential that "trying" situations which increase the patient's tension be avoided.

The patient who has had an adrenalectomy will have to take cortisone, in some form, for the remainder of her life. This is often called "replacement therapy." It is strongly recommended that the patient carry some type of written information on her person indicating her need for maintenance doses of cortisone. It is vital that both the patient and her family understand that there must be no exceptions to the cortisone regimen outlined by the physician since this substance is essential for life.

Cortisone therapy may require dietary modification. This is highly individual, based on the patient's response to treatment and previously existing disease.

The sodium-retaining properties of cortisone are well known. Restriction of dietary sodium may be necessary to prevent edema formation. This is particularly true for patients with heart, kidney, or liver disease, who may have a predisposition to accumulate fluid. The problem is complicated by the cancer patient's need for protein which is notoriously high in naturally occurring sodium. In addition, a flagging appetite may fail to respond to unsalted foods. Suggestions for adding flavor to the sodium restricted diet will often be needed. See appendix II.

Prolonged cortisone therapy may also lead to gastric disturbances (including ulcers) or diabetes, both of which require further dietary modification.

c. Hypophysectomy

Recently it has been found that patients with certain hormone dependent breast tumors respond well to the removal of the pituitary gland. This may be done surgically or by radiation. In these women alteration of the hormonal status influences the course of the disease and causes a temporary remission. The entire mechanism is still not understood, and much remains to be learned about this form of therapy.

After the hypohysectomy extensive replacement therapy must be carried out since the pituitary gland is the seat of many important "body regulators." Among the most important substances needed by these patients are cortisone and desiccated thyroid. These must be taken for the remainder of the patient's life. Some patients, though not all, may have a resulting interference in the water balance of the body. Occasionally diabetes insipidus occurs and treatment with pitressin may be instituted to replace the missing pituitary factor. Sodium restriction may be necessary for some patients.

d. Simple Mastectomy

This is sometimes done as a palliative measure to remove an ulcerating lesion of the breast and to increase the patient's comfort.

2. Hormone Therapy. Estrogens

Estrogenic hormones are used primarily to treat advanced breast cancer in postmenopausal women. They are particularly helpful in controlling soft-tissue manifestations of disease. Since sodium retention may lead to edema formation particularly in the older age group, the physician may restrict dietary sodium. In general, only moderate restriction of sodium is advised since food intake is apt to be low. Nausea and vomiting may further complicate the dietary problem. Later effects include retention of fluid in the tissues (estrogens promote sodium retention in the body) uterine bleeding, urinary frequence, and incontinence. In an occasional patient hypercalcemia occurs with symptoms of nausea, vomiting, lethargy, dehydration, mental aberration, and coma.

b. Androgens

Androgenic hormone therapy is used to treat advanced cancer of the breast in women of any age. Androgens are particularly useful in counteracting metastic disease in the bones (skeletal metastases). Every effort must be made to mobilize the patient receiving androgens, even though this may be somewhat difficult. This therapy is used mainly for patients with extensive bone disease, and ambulation of these patients is very essential to promote retention of calcium in the body.

Unfavorable effects of androgen therapy consist of masculiniza-tion-hirsutism, facial flush, acne, deepening of the voice, thinning of the hair, and increase in libido. Fluid retention may also occur as it does with estrogenic therapy. These symptoms are extremely distressing to most patients and for this reason physicians sometimes hesitate to use large doses.

c. Cortisone

Massive doses of cortisone are sometimes used to depress pituitary function and produce secondary atrophy of the adrenal cortex. In this way regressions similar to those produced with other hormones can sometimes be achieved. Adverse effects consist mainly of "moon" faced appearance, fluid retention, hypertension, diabetes, gastric disturbances, increased susceptibility to infection and possible adrenal failure under increased stress.

3. Radiation Therapy

X-ray is used as a palliative agent for advanced cancer of the breast which is incurable. This may be given by conventional X-ray units of varying voltages, super-voltage units, or by means of teletherapy units utilizing cobalt-60 (or some other radioisotope). Radiation often affords prompt relief from pain, and may result in fairly long remissions from the disease. Bone metastases respond particularly well. (See section on nursing care of patients receiving radiation therapy.)

Radium, in the form of radium needles, is sometimes the treatment of choice-particularly for the very obese patient. The needles are placed in layers within or beneath the tumor and are left in for prescribed periods of time (usually several days).

Injections of radioactive phosphorus (P32) are also utilized as a palliative measure. The radioactive isotope is administered postoperatively into the operative site. Injections continue until a total treatment dose (usually 12 to 15 millicuries) has been reached. This may take seveeal weeks or a month.

All of the treatments discussed under palliative therapy are used to halt progression of the disease. Eventually breast cancer treated by any of these methods will recur.