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Breast Health Navigator Manual

Table of Contents & Index

Refer to last four swatches in swatch sample window Navigator Role The Front Line Challenge of the Breast Health Navigator...... 3 Overview of Breast Health Navigator Role...... 4 Navigator’s Role in Accreditation...... 8 Breast Health Navigation Process: EduCare Clinical Guidelines...... 9 Patients’ Adaptive Tasks Change Throughout the Continuum of Care...... 11

Supplemental Information Breast Health Navigator: A Paradigm Shift in Breast Health Care...... 14 Lexington Medical Center Case Study...... 22 EduCare Breast Cancer Navigator Clinical Guidelines...... 25 National Accreditation Program for Breast Centers (NAPBC) Breast Center Accreditation Standards...... 28 Nursing-Sensitive Patient Outcomes (NSPOs) Across the Breast Care Continuum...... 31

Historical Overview Historical Overview of the Breasts...... 34

Statistics and Risk Factors Breast Cancer Statistics and Risk Factors...... 45 Breast Cancer Survival Statistics...... 47 Breast Cancer Risk Factors: What Do We Tell Our Patients?...... 49 Breast Cancer Risk Factors...... 52 Prevention of Breast Cancer...... 58

Supplemental Information CDPH Algorithm 1: Assessment of Risk...... 60 CDPH Algorithm 1: Risk Assessment Table...... 61 Quiz: What Do You Know About Breast Cancer?...... 62

Anatomy and Physiology Anatomy and Physiology of the Female Breast...... 65 Internal Structures of the Breasts...... 67 Life Cycle of Breast Development...... 69 Why Women Are Confused About Breast Exam...... 71 Breast Lymphatics...... 72

Supplemental Information Internal Structure of the Female Breast...... 75 Lymphatic Drainage...... 76 Blood Supply...... 77

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 Benign Breast Conditions Benign Breast Conditions and Diseases...... 80 Normal Breast Conditions & Breast Related Findings...... 82 Abnormal Breast Development Conditions...... 83 »»Accessory Breast Tissue...... 83 Abnormal Breast Skin Infections and Lesions...... 85 »»Fibrocystic Breasts...... 86 »»Breast Cysts...... 87 »»Galactocele...... 89 »»Hematoma...... 89 »»Fibroadenoma...... 89 »»Sclerosing Adenosis...... 91 Inflammatory Conditions...... 92 »»Mastitis...... 92 »»Breast Abscess:...... 92 »»Fat Necrosis...... 93 »»Duct Ectasia...... 94 »»Mondor’s Disease...... 95 Benign Tumors...... 97 »»Papilloma...... 97 »»Lipomas...... 97 »»Diabetic Mastopathy...... 97 Intermediate Tumors...... 98 »»Phyllodes Tumor...... 98 »»Atypical Hyperplasia...... 98 »»Radial Scars...... 98 »»Nipple and Areola Lesions...... 99 Benign Diseases Increase In Risk for Breast Cancer...... 100

Supplemental Information Benign Breast Disorders: Frequency of Occurrence...... 102 CDPH Algorithm 5: Breast Skin Changes / Nipple Retraction...... 103

Diagnosis of Breast Disease Diagnostic Evaluation for Breast Diseases...... 106 Clinical Breast Exams and Breast Self Exams...... 107 Mammography...... 109 »»Mammography Markers...... 111 Digital Mammography...... 112 3-D Mammography...... 114 CAD: Computer Aided Detection...... 115 What Navigators Need to Know about Mammography Results...... 117

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 Breast MRI...... 120 Other Imaging Modalities...... 122 Breast Biopsy Procedures...... 124 »»Fine Needle Aspiration (FNA)...... 125 »»Punch Biopsy...... 125 »»Core Needle Biopsy Procedures...... 125 »»Vacuum-Assisted Biopsy Procedures...... 126 »»Ultrasound Guided Core Biopsy...... 126 »»Stereotactic Biopsy Procedures...... 127 »»Microclip Placement After Biopsy...... 128 Needle Localization for Surgery...... 130 Surgical Biopsy...... 131 The Challenge of Clinical Improvement in the Management of Breast Diseases...... 132 »»Tips for Implementing Patient-Focused Diagnostic Care...... 132 »»Primary Care Inclusion...... 132 »»Closing Gaps in Care Causing Out Migration...... 133 »»The Secret to Reducing Diagnostic Turn Around...... 134 Supplemental Information CDPH: Breast Cancer History and Risk Assessment...... 136 ICSI Algorithm I: Evaluation of Breast Mass...... 138 CDPH Algorithm 2: New Palpable Mass...... 139 CDPH Algorithm 3: Abnormal Screening Mammogram with Normal CBE...... 140 ICSI Algorithm V: Image-Directed Core Needle Biopsy...... 141 Sample Physician Request: Standing Orders...... 142 Sample Prescription Pad: Breast Diagnostics...... 143 Glossary of Mammography Statistical Terms...... 144 NMD Short Form for Minimal Data Collection version 3.1...... 146 Breast Imaging Reporting and Data System™ (BI-RADS™)...... 149 Biopsy Types...... 151 Biopsy Risks...... 152 American College of Radiology Definitions of Masses...... 153 Standing Orders for Patients Recommended to Have a Breast Biopsy...... 158 CDPH Algorithm 7: Breast Biopsy...... 159 BI-RADS™ Pathology Codes Abbreviations...... 160 Clinical Breast Exams...... 162 CDPH: CBE Results Documentation Form...... 175 CDPH: Core Competencies of Clinical Breast Examination...... 176 Measuring Productivity...... 177 Anticipatory Scheduling for Mammography...... 179

Breast Pain Solving the Mystery of Breast Pain...... 182 »»Breast Pain...... 182

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 Cyclic Pain...... 183 »»The Drug Connection...... 184 »»Cyclic Pain Management...... 187 »»Physiological Conditions Promoting Breast Pain...... 188 »»Prescription Medications to Treat Breast Pain...... 188 Noncyclic Pain...... 189 »»Benign Breast Conditions: Noncyclic Pain...... 189 »»Chest Wall Conditions That May Cause Noncyclic Pain...... 190 »»Musculoskeletal Conditions...... 191 Cancer and Breast Pain...... 193 Keeping a Calendar Record of Pain:...... 195

Supplemental Information Types and Descriptions of Breast Pain...... 197 Comparison of Cyclic, Noncyclic, Musculoskeletal and Chest Wall Pain...... 198 Breast Pain Treatments...... 199 Benign Conditions Causing Breast Pain...... 200 Conditions Mistaken for Noncyclic Breast Pain...... 201 CDHS Algorithm 6: Breast Pain in a Non-Lactating Woman...... 203 Identifying Drugs That May Cause Breast Pain...... 204 CDHS Algorithm 6: Breast Pain in a Non-Lactating Woman...... 206

Breast Discharge Breast Discharge...... 209 Physiological Discharge: A Normal Discharge...... 211 Pharmacological Discharge...... 212 Pathological Discharge: Benign and Cancerous Causes...... 213 »»Benign Breast Disease Discharge...... 213 »»Cancerous Diseases Producing Discharge...... 213 Diseases That May Produce Discharge as a Side Effect...... 215 Ductography...... 216 Breast Discharge History and Assessment...... 219

Supplemental Information ICSI Algorithm II: Evaluation of the Breast for Nipple Discharge...... 222 CDPH Algorithm 4: Spontaneous Unilateral Nipple Discharge (Non-Lactating)...... 223 Breast Discharge Color Evaluation...... 224 Identifying Drugs That May Cause Breast Discharge...... 225

Male Breast Disease The Challenge of Identifying Male Breast Disease...... 228 Gynecomastia...... 229

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 What About Male Breast Cancer?...... 233 »»Treatment for Male Breast Cancer...... 235 Supplemental Information Gynecomastia Evaluation...... 238 Treatment of Male Gynecomastia...... 239 Gynecomastia Promoting Drugs...... 240 Treatment Options for Male Breast Cancer NCI Professional Summary...... 241

Understanding Breast Cancer What Is Breast Cancer?...... 301 What Causes Breast Cancer?...... 303 Breast Cancer Types...... 304 »»Helping Patients Understand Types of Cancer...... 305 Ductal Carcinoma In Situ Management...... 308 »»Scoring DCIS Characteristics for Treatment Decisions...... 309 Invasive (Infiltrating) Ductal Carcinoma...... 311 Lobular Carcinomas...... 312 Infiltrating Lobular Carcinoma...... 313 Paget Disease...... 314 Mucinous Carcinoma...... 315 Papillary Carcinoma...... 316 Medullary Carcinoma...... 317 Tubular Carcinoma...... 318 Inflammatory Carcinoma...... 319 Metastatic Cancer Found in the Breast...... 321 Pathology Reports: What Navigators Need to Understand...... 322 Pathology Tumor Studies...... 326 Vascular and Lymphatic Invasion...... 328 Understanding Metastatic Spread of Breast Cancer...... 329 Pathology Reports Reveal Unique Characteristics of a Patient’s Breast Cancer...... 331

Supplemental Information How Breast Cancer Is Staged...... 333 Molecular Subtypes of Breast Cancer...... 339

Navigator as Coach Navigator as Coach...... 342 Cancer Diagnosis...... 343 Developing a Relationship of Trust and Connection...... 346 Assessing Patient Treatment Barriers...... 353 Developing Navigator Communication Skills...... 356 The Coping Assessment...... 360

Supplemental Information Navigator's Pathway: Patient Navigation...... 366 Nurse Navigator Patient Interview Tips...... 370 Breast Health Navigator: Patient Assessment...... 371 Patient Treatment Barriers Assessment...... 374 Decision-Making and Support Styles Assessment...... 377 Therapeutic Communication Guidelines...... 379 Patient Coping Strategies During Breast Cancer...... 380 Key Cultural Values and How They Affect Care...... 381 Comparing Cultural Norms and Values...... 382 Suggestions for Healthcare Professionals Regarding Cross-Cultural Communication.....383 Patient Navigation Acuity Scale...... 384 The Stress Response: Fight or Flight...... 385

Surgical Decisions Surgical Decisions...... 388 Helping Patients Understand Surgical Decisions...... 389 Preparing Patients for the Surgical Experience...... 391 Surgical Options...... 394 »»Breast Conservation...... 394 »»Sentinel Node Biopsy...... 396 »»Mastectomy...... 397 »»Skin-Sparing Mastectomy...... 397 »»Prophylactic Mastectomy...... 399 »»Outpatient Breast Surgery...... 399 »»Nipple-Sparing Mastectomy...... 399 »»Oncoplastic Surgery...... 400 »»Decisional Tool Aids...... 400 Post Operative Nursing Care...... 402 Post Surgical Complications...... 403 Uncommon Post-Surgical Problems...... 405 Discharge Instructions...... 406

Supplemental Information Second Opinions...... 408 Surgical Decision Evaluation...... 411 Drain Bag Instructions...... 415 Mastectomy Discharge Instructions...... 416 Lumpectomy Discharge Instructions...... 418

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 Breast Reconstruction Breast Augmentation...... 422 Implant Surgical Techniques...... 424 Breast Implant Risks...... 425 Imaging the Augmented Breast...... 428 Breast Reduction...... 429 Breast Mastopexy...... 430 Breast Cancer Reconstruction...... 431 Reconstruction Types...... 433 »»Autologous (Own Body Tissue) Reconstruction...... 434 »»Autologous Reconstruction – Perforator Flaps...... 435 »»TRAM Flap (Transverse Rectus Abdominis Myocutaneous)...... 435 »»Epigastric Perforator Procedures...... 436 »»Latissimus Dorsi Myocutaneous Flap...... 437 »»TAP (Thoracodorsal Artery Perforator)...... 438 »»Free Flap Reconstruction Procedures...... 438 »»S-GAP (Superior Gluteal Artery Perforator) I-GAP (Inferior Gluteal Artery Perfortor)...... 439 »»Nipple and Areola Reconstruction...... 439 Oncoplastic Breast Cancer Surgery with Reduction...... 440 Radiation Therapy to Reconstructed Breast...... 441 Necrosis of Breast Tissue...... 442 Patient Reconstruction Education...... 443 What’s New? Breast Cell Grafts...... 444

Supplemental Information Comparison of Breast Reconstrution Procedures...... 446 Complications and Risks of Reconstruction Procedures...... 447 Breast Implants...... 448 DIEP (Deep Inferior Epigastric Perforator)...... 451 Inferior (Lower) Gluteus (Buttock) Flap...... 454 Latissimus Dorsi (Back Flap)...... 457 Nipple and Areola Reconstruction...... 459 Reconstruction Flap Types...... 461 S-GAP (Free-Superior Gluteal Artery Perforator)...... 463 TAP (Thoracodorsal Artery Perforator)...... 466 TRAM Flap...... 469 Breast Implant Types...... 472 Additional Breast Reconstruction Resources...... 473

Breast Cancer Treatment Breast Cancer Treatments...... 476 Factors That Determine Treatment Selection...... 478

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 »»Stage of Cancer: Stage 0 to IV...... 478 »»Understanding T (Tumor)...... 479 »»Understanding N (Node)...... 480 »»Understanding M (Metastasis)...... 480 Understanding NCCN Treatment Guidelines for Breast Cancer...... 481 Treatment Options...... 482 Surgery and Radiation Therapy for Breast Cancer...... 483 »»Stage 0 – Guidelines for Breast Cancer...... 484 »»Stage 1, 2, Some 3s – Guidelines for Breast Cancer...... 484 »»Stage 4 – Guidelines for Breast Cancer...... 485 Recurrent Breast Cancer Guidelines...... 486 Chemotherapy...... 488 Biological Response Modifiers – Targeted Therapy...... 490 Gene Diagnostic Testing: Individualized Tumor Profiles...... 491 Hormonal Therapy...... 493 New Drugs, Tests and Therapies...... 494 Understanding Radiation Therapy...... 495 Monitoring Treatment Effectiveness During Treatment...... 497 Surveillance after Breast Cancer...... 498 Complementary and Alternative Therapies...... 499 Staying Up-To-Date: Breast Cancer Updates...... 501

Supplemental Information Estrogen and Progesterone Receptor Status...... 503 Hormonal Therapy Classes...... 505 Five Year Relative Survival Rates...... 506 TNM Staging of Breast Cancer...... 507 Oncotype DX®...... 508 Chemotherapy: Patient Infusion Tips...... 510 Chemotherapy Drugs: Generic and Brand Names...... 512 Understanding Nadir from Chemotherapy...... 513 Chemotherapy Drugs for Invasive Breast Cancer...... 515 Nausea and Vomiting Management...... 517 Radiation Therapy Complications in Conservatively Treated Patients...... 521 Telephone Assessment After Chemotherapy...... 522 ASCO Recommended Breast Cancer Follow-Up...... 523 Breast Cancer Follow-Up and Management in the Adjuvant Setting: Patient Flow Sheet...... 525 ASCO Treatment Algorithm for Bone Health in Patients with History of Breast Disease...... 526 Additional Breast Cancer Treatment Resources...... 527

Pregnancy and Breast Cancer Pregnancy and Breast Cancer...... 530 Imaging During Pregnancy...... 531

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 Biopsy Procedures...... 532 Positive Breast Cancer Diagnosis Staging...... 533 Treatment Decisions...... 534 »»First Trimester...... 534 »»2nd Trimester / Early 3rd Trimester...... 534 »»Late 3rd Trimester...... 535 Understanding Surgical Guidelines...... 536 Understanding Chemotherapy Risk and Out-Comes...... 537 Pregnancy After Breast Cancer...... 539

Supplemental Information NCI Summary: General Information About Breast Cancer Treatment and Pregnancy....541 Additional Pregnancy & Breast Cancer Resources...... 543

Fertility Issues Future Fertility of Patients Treated With Chemotherapy...... 546 Planning Alternative Fertility Options...... 548 Patient Information on Fertility...... 550

Supplemental Information Female Infertility: Detailed Information...... 552 Fertility Preservation...... 555

Recurrent Breast Cancer Recurrent Breast Cancer...... 559 The Emotional Experience of Recurrence...... 560 Recurrent Breast Cancer...... 562 Survival: Recurrent Breast Cancer...... 564 Recurrent Breast Cancer Diagnostic Work-Ups and Treatments...... 565 Recurrent Treatment Selection...... 567 Recognizing Characteristics of Different Types of Recurrences...... 568 »»Bone Metastasis...... 568 »»Spinal Cord Metastasis...... 568 »»Brain Metastasis...... 569 »»Carcinomatous Meningitis...... 569 »»Lung Metastasis...... 569 »»Liver Metastasis...... 570 »»Bone Marrow Metastasis...... 570 Recurrent Breast Cancer Clinical Pictures...... 571 Recognizing Radiation Induced Angiosarcoma...... 573 Navigator Recurrent Guidelines...... 574

Sexuality After Cancer Sexuality after Breast Cancer...... 584 Sexuality Education...... 587 Patient’s Views of Sexual Education...... 589 Identifying Patient Barriers to Sexual Functioning...... 590 Patient Sexuality Discussion...... 591 Identifying Causes of Sexual Problems...... 593 Preparing Patients for Impact of Chemotherapy...... 594 When Systemic Estrogen Therapy Is Not an Option...... 598 »»Vaginal Dryness...... 598 »»Painful Intercourse...... 599 »»Urinary Tract...... 599 »»Vascular System...... 599 »»Brain/Nervous System...... 601 »»Depression...... 601 »»Sexual Changes...... 603 »»Skeletal Changes...... 603 »»Heart Disease...... 604 »»Other Factors Contributing to Sexual Functioning...... 604 Understanding the Female Sexual Response Cycle...... 606 »»Stage 1: Desire...... 606 »»Stage 2: Excitement...... 607 »»Stage 3: Orgasm...... 608 »»Stage 4: Resolution...... 608 What’s New?...... 610 Single Women and Sexuality...... 611 Navigator Support...... 613

Supplemental Information Menopausal Side Effects from Chemotherapy...... 615 STAR Trial Non-Hormonal Hot Flash Management...... 618 Government-Approved Postmenopausal Osteoporosis Drugs in the US and Canada...... 619 Non-Hormonal/Non-Pharmacologic Interventions to Give Patients Back Their Sex Life...... 620 FSFI: Female Sexual Function Index...... 622 FSI: Female Sexual Function Index Scoring...... 625 Treating Vaginal Atrophy...... 628 Interventions Tested for Vaginal Dryness and/or Loss of Libido...... 630 Additional Sexuality After Cancer Resources...... 631

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 Hereditary Breast Cancer Understanding Hereditary Breast Cancer...... 634 3 Genetic Categories of Breast Cancer...... 636 Role of Genes in Hereditary Breast Cancer Development...... 638 Understanding Hereditary Transfer of Mutated Genes in Family...... 639 How Common are BRCA Gene Mutations?...... 640 Positive BRCA Carrier: Difference in Personal Cancer Risks...... 641 Identifying People With Potential Hereditary Gene Mutation...... 642 Benefits of Breast Cancer Genetic Testing...... 643 Preliminary Assessment for Hereditary Cancer...... 644 Assessment Tools for Hereditary Breast Cancer...... 645 Genetic Testing Procedure...... 646 What Patients Fear About Genetic Testing...... 647 Genetic Testing Results...... 648 Treatment Options for Positive Carriers...... 650 Hereditary Breast Cancer Summary...... 653

Supplemental Information Hereditary Cancer Questionnaire: Myriad...... 655 BRAC Analysis Test Request Form: Myriad...... 656 Risk Assessment for Hereditary Breast and Ovarian Cancer Syndrome: Myriad...... 659 Mutation Prevalence Tables: Myriad...... 660 Additional Hereditary Breast Cancer Resources...... 661

Survivorship Challenges Mastering the Challenges of Survivorship...... 664 Psychological Adjustment...... 665 »»Recognizing the Signs and Symptoms of Psychological Distress...... 665 »»Recognizing Coping Strategies...... 667 »»Common Periods of Distress Vulnerability...... 667 »»Is Patient Experiencing Anxiety Or Depression?...... 669 »»How Navigators Help Patients Resolve Distress Symptoms...... 669 Lymphedema...... 671 »»The Role of the Navigator in Lymphedema Management...... 671 »»Lymphedema Staging: 4 Stages (Stage 0 - Stage 3)...... 673 »»Treatment for Lymphedema...... 675 »»Breast Lymphedema...... 677 Breast Self-Exam after Surgery...... 678 Diet and Nutrition...... 680 Exercise...... 681 Prosthesis Selection...... 683 Employment Issues...... 684 Navigator as Coach...... 686

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 Supplemental Information Quality of Life Assessment...... 688 Adjusting to Loss Assessment...... 689 Anxiety Assessment...... 691 Mood Assessment: Post-Treatment...... 693 Lymphedema Assessment...... 695 Range of Motion Assessment...... 697 Massage Guidelines...... 698 Nutritional Evaluation...... 699 Nurse Navigator Physical Activity Screening...... 701 Nurse Navigator Fatigue Assessment...... 703 Distinguishing Between Fatigue and Depression...... 704 Alternative Diets Cancer Patients May Mention...... 705

Spiritual Needs Patients’ Spiritual Needs...... 709 Understanding the Signs of Suffering...... 711 Navigator Intervention To Address Spiritual Needs...... 713 Navigator Questions to Elicit Patient’s Spiritual Needs...... 714

Supplemental Information Religious Influence on Treatment Decisions...... 717 Religious Beliefs and Rituals During Illness and Death...... 718 Islam Health Beliefs...... 720 Additional Spiritual Needs Resourcs...... 725

Terminal Patient Empowering Patients To Walk Through the Dying Process With Courage...... 729 How Healthcare Providers Are Failing Patients...... 730 Developing Care Plans That Really Care...... 731 Patient End-of-Life Assessment...... 732 Life Review – Discovering Who They Were in the Past...... 733 Navigator Facilitation of End-Of-Life Decisions...... 734 Family Members During End-of-Life Care...... 736 Why Do I As A Navigator Do This Work?...... 737 What Patients Want...... 737

Supplemental Information Navigator End of Life Goals Record...... 739 Nurse's Role in Supporting Bereaved Children...... 740 Children's Understanding of Death...... 741 Location of My Important Papers...... 745 Living Wills: Advanced Directives...... 746 Additional Terminal Patient Resources...... 747

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 Support Programs Supporting the Family Unit...... 750 The Support Partner...... 753 Support Group for Men...... 756 Cancer: A Family Challenge...... 757 Breast Cancer Support Groups...... 761 »»Support Group Formation...... 762 Breast Cancer 101...... 763 Metastatic Support Groups...... 764

Supplemental Information Ideas for Successful Support Programs for Breast Cancer Patients and Their Families...... 766

Survivorship Programs Designing an Effective Navigation & Survivorship Program...... 773 »»Navigation Process and Patient Navigator: Standard 3.1...... 773 »»Barriers Assessment: Standard 3.1...... 774 »»Distress Assessment: Standard 3.2...... 774 »»Survivorship Care Plan: Standard 3.3...... 775 Understanding Navigator’s Role in Meeting New Guidelines...... 778 Post-Treatment Education...... 779 Survivorship Programs...... 780

Supplemental Information Distress Management: NCCN Guidelines (Version 1.2011)...... 782 Cancer Treatment Plan and Summary (ASCO)...... 783 NCI Community Cancer Centers Program: Breast Cancer Survivorship Care Plan...... 786 Potential Survivorship Services Healthcare Common Procedure Coding System (HCPCS)...... 788 Additional Survivorship Programs Resources...... 790

Navigator Program Organization Navigator Program Organization...... 793

Supplemental Information Planning Guidelines for Breast Health Navigator...... 801 Patient Navigation Software Selection Guide...... 811 Breast Health Navigator: Patient Weekly Contact Record...... 813 Breast Health Navigator: Patient Monthly Contact Record...... 815 Patient Education Record...... 816

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 Sample Letter: Breast Health Navigator Introduction...... 817 Sample Letter: Explanation of Breast Health Navigator Role...... 818 Sample Letter: Evaluation of Breast Health Navigator Services...... 819 Monitoring Navigation Service Outcomes...... 822 Community Advisory Council...... 823 Breast Health Navigator Resources...... 824

Breast Center Marketing Lexington Medical Center: Breast Services Redesign, 1997...... 837 Navigator Role: Financial Benefits...... 839 »»Study Proves Financial Benefits of Navigation...... 840 Marketing a Breast Center...... 842 »»Where Does a Successful Marketing Plan Begin?...... 843 »»Identify Your People to Market Program...... 844 »»Gathering Ancillary Support for Your Program...... 845 »»New Center Opening...... 846 »»General Marketing Approach...... 847 Breast Multidisciplinary Conferences...... 850 Breast Health Specialty Clinics...... 853

Supplemental Information Interdisciplinary Conferences...... 858 Summary of Strategies for Conducting Effective Interdisciplinary Pretreatment Planning Conferences...... 862 Interdisciplinary Breast Conference Worksheet...... 863 Marketing Your Breast Health Center to Physicians...... 865 Breast Center Survey...... 869

EduCare Information Judy C. Kneece, RN, OCN Background and Qualifications...... 3 EduCare Background...... 6

Supplemental Information Breast Cancer Treatment Handbook...... 9 Breast Cancer Survivorship Care Plan...... 10 Breast Cancer Support Partner Handbook...... 11 COPE Library: Breast Health Edition...... 12

range of motion ... 697 A treatment barriers ... 374 Page Directory aberration ... 80 Ataxia-Telangiectasia ... 53 abraxane ... 494 atrophic vaginitis ... 597 Navigator Role...... 1-31 abscess ... 80, 92, 189 atypical cells ... 80 Historical Overview...... 32-42 accelerated beam radiation ... 495 atypical hyperplasia ... 98 Statistics and Risk Factors...... 43-60 accessory breast tissue ... 83 axillary lymph node surgery ... 483 accreditation ... 8 axillary tail ... 65 Anatomy and Physiology...... 61-72 acellular dermal matrix ... 434 Benign Breast acne ... 85 Conditions...... 73-95 acuity scale ... 384 B Baker Grades ... 425 Diagnosis of Breast adaptive stages ... 11 Disease...... 96-166 barriers resolution ... 354 adenomyoepthelioma ... 100 Breast Pain...... 167-192 adenosis ... 100 benign breast disorders ... 80, 102 Breast Discharge...... 193-209 adjustment disorder ... 665 bilateral bloody discharge ... 212 Male Breast Disease...... 210-224 adjuvant treatment ... 488 birth control pills ... 248 blood supply ... 77 Hormones and Breast adriamycin ... 488 Disease...... 225-275 advanced directives ... 746 bone marrow metastasis ... 570 bone metastasis ... 568 Understanding Breast advisory council ... 823 Cancer...... 276-307 brachytherapy ... 495 albumin ... 700 Navigator as Coach...... 308-349 brain metastasis ... 569 alkylating agents ... 488 Surgical Decisions...... 350-381 alopecia ... 604 BRCA1 ... 634 Breast Reconstruction...... 382-430 Americans with Disabilities Act ... 684 BRCA2 ... 634 BRCA positive surveillance ... 650 Breast Cancer ANDI ... 80 Treatment...... 431-475 anthracyclines ... 488 breast development ... 69 Pregnancy and Breast antidepressants ... 602 Cancer...... 476-487 development stages ... 69 antimetabolites ... 488 Fertility Issues...... 488-499 internal structure ... 67, 75 anxiety ... 669 Recurrent Breast breast augmentation ... 422 aromatase inhibitors ... 493, 597 Cancer...... 500-520 breast biopsy procedures ... 124 Ashkenazi Jewish ... 642 Sexuality After Breast aspiration ... 88 breast cancer ... 301 Cancer...... 521-564 assessment causes ... 303 Hereditary Breast treatment barriers ... 353, 374 characteristics ... 301 Cancer...... 565-587 assessments growth rate ... 301 Survivorship Challenges...... 588-628 adjusting to loss ... 689 helping patients understand ... 305 anxiety ... 691 histological types ... 323 Spiritual Needs...... 629-645 barriers ... 773 metastatic spread ... 329 Terminal Patient...... 646-663 chemotherapy follow-up ... 522 molecular subtypes ... 339 Support Programs...... 664-683 coping ... 360 subtypes ... 305 Survivorship decision-making ... 377 treatment ... 476 Programs...... 684-703 distress ... 773 types ... 304, 477 Navigation Program Organization...... 704-747 end-of-life ... 732 updates ... 501 Breast Center fatigue ... 703 breast cancer staging ... 330, 333, 478, 484 Marketing...... 748-783 lymphedema ... 695 Breast Cancer Support Partner EduCare...... 784-795 mood: post-treatment ... 693 Handbook ... 881 patient assessment ... 371 Breast Cancer Survivorship Care Plan ... quality of life ... 688 880

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 Breast Cancer Treatment Handbook ... chemotherapy ... 488 879 menopausal side effects ... 615 breast conservation ... 394, 483 menopausal symptoms ... 594 Page Directory breast cyst ... 87 patient infusion tips ... 510 Navigator Role...... 1-31 breast discharge ... 209 quality of life impact ... 597 Historical Overview...... 32-42 color evaluation ... 88, 209, 214, 224 chemotherapy drugs ... 488, 512, 515 Statistics and Risk evaluation ... 210 chest radiation ... 54 Factors...... 43-60 history and assessment ... 219 children's educational classes ... 759 Anatomy and medications affecting breast ... 225 clinical depression ... 665 Physiology...... 61-72 breast gland ... 65 clinical guidelines, EduCare ... 9 Benign Breast Conditions...... 73-95 breast herpes simplex ... 86 clonidine patch ... 600 breast location ... 65 coding ... 788 Diagnosis of Breast Disease...... 96-166 breast lumps ... 71 colloid carcinoma ... 315 Breast Pain...... 167-192 breast lymphedema ... 677 comedo pattern ... 310 Breast Discharge...... 193-209 breast massage ... 187 Commission on Cancer (CoC) ... 8, 773 breast mass evaluation ... 138 communicating bad news ... 356 Male Breast Disease...... 210-224 breast MRI ... 120 communication barriers ... 353 Hormones and Breast Disease...... 225-275 breast MRI biopsy ... 121 communication guidelines ... 379 Understanding Breast breast nodularity ... 71 complementary and alternative medicine Cancer...... 276-307 breast pain ... 80, 182 (CAM) ... 499 Navigator as Coach...... 308-349 evaluating ... 193 Complete Decongestive Therapy (CDT) hormonal changes ... 183 ... 676 Surgical Decisions...... 350-381 medications ... 188 complications, post surgical ... 403, 405 Breast Reconstruction...... 382-430 medications affecting breast ... 204 compounding pharmacists ... 603 Breast Cancer treatments ... 199 compression ... 676 Treatment...... 431-475 types ... 197 computer aided detection (CAD) ... 115 Pregnancy and Breast Cancer...... 476-487 breast reduction ... 429 computerized thermal imaging (CTI) ... Fertility Issues...... 488-499 breast self exam after surgery ... 678 122 breast self exam controversy ... 107 Contura ... 495 Recurrent Breast Cancer...... 500-520 breast services redesign ... 837 cooper’s ligaments ... 68 COPE Library: Breast Health Edition ... Sexuality After Breast 882 Cancer...... 521-564 coping strategies ... 667 Hereditary Breast C Cancer...... 565-587 coping styles ... 732 caffeine ... 186 core needle biopsy ... 125 Survivorship calcifications ... 117 Challenges...... 588-628 costochondritis ... 191 calendar record (pain) ... 195 Spiritual Needs...... 629-645 Cowden syndrome ... 53 cancer progression ... 306 cultural barriers ... 354, 381 Terminal Patient...... 646-663 cancer vs gynecomastia ... 236 cyclic pain ... 183, 187 Support Programs...... 664-683 Candida Albicans ... 85 cyclophosphamide ... 488 Survivorship capecitabine ... 494 Programs...... 684-703 cystosarcoma ... 98 capsular contracture ... 425 cysts ... 80 Navigation Program carbuncles ... 85 Organization...... 704-747 cytoxan ... 488 carcinomatous meningitis ... 569 Breast Center cardiomyopathy warning ... 490 Marketing...... 748-783 caregiver. See also support partner D EduCare...... 784-795 CDH1 Gene ... 53 DCIS (ductal carcinoma in situ) ... 308 cell grafts ... 444 death cellular debris ... 94 children's understanding ... 741 cellulitis ... 190, 673 dense breast tissue ... 54 chemoprevention ... 58, 650 depression ... 601, 669

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 DES therapy ... 55 epirubicin ... 488 diabetic mastopathy ... 97 epithelial turnover ... 80 diagnostic wait-time ... 837 eribulin mesuflate ... 494 Page Directory DIEP ... 437, 451 ER/PR status ... 503 Navigator Role...... 1-31 diet and nutrition ... 680 ER/PR variables ... 326 Historical Overview...... 32-42 digital mammography ... 112 Estrace ... 599 Statistics and Risk discharge, pathological ... 213 estradiol ... 245 Factors...... 43-60 discharge, pharmacological ... 212 Estring ... 599 Anatomy and discharge, physiological ... 211 estriol ... 245 Physiology...... 61-72 disease progression indicators ... 497 estrogen ... 55, 69, 245 Benign Breast Conditions...... 73-95 distress ... 666 estrogen replacement ... 259 CoC guidelines ... 775 estrogen replacement therapy ... 251, Diagnosis of Breast Disease...... 96-166 monitoring ... 666 278, 285 Breast Pain...... 167-192 NCCN guidelines ... 775, 782 estrone ... 245 Breast Discharge...... 193-209 periods of vulnerability ... 667 evening primrose oil ... 187 resolving ... 669 excisional biopsy ... 131 Male Breast Disease...... 210-224 understanding ... 666 exercise ... 676, 681 Hormones and Breast Disease...... 225-275 docetaxel ... 488 external beam radiation ... 495 Understanding Breast dose-dense chemotherapy ... 488 Cancer...... 276-307 doxorubicin ... 488 Navigator as Coach...... 308-349 drain bag instructions ... 408 F Surgical Decisions...... 350-381 drain bulb management ... 392 familial breast cancer ... 636 drain removal ... 404 Family and Medical Leave Act ... 684 Breast Reconstruction...... 382-430 ductal carcinoma in situ ... 214, 308. See family care barriers ... 353 Breast Cancer also DCIS family history ... 53 Treatment...... 431-475 ductal ectasia ... 100 family support ... 750, 757 Pregnancy and Breast Cancer...... 476-487 ductal hyperplasia ... 100, 229 fatigue ... 604, 681 Fertility Issues...... 488-499 ductal involution ... 80 fat necrosis ... 93, 100 ductal lavage ... 122 Female Sexual Function Index (FSFI) ... Recurrent Breast Cancer...... 500-520 ductal papilloma ... 213 622 fertility Sexuality After Breast duct ectasia ... 80, 94, 190 Cancer...... 521-564 ductography ... 216 additional resources ... 550 Hereditary Breast chemotherapy impact ... 547 duct removal ... 217 Cancer...... 565-587 fertility preservation options ... 548, Survivorship 555 Challenges...... 588-628 future fertility ... 546 E Spiritual Needs...... 629-645 treatment impact ... 546 ECOG performance status ... 487 Terminal Patient...... 646-663 eczema, nipple ... 85 fibroadenoma ... 80, 89, 100 Support Programs...... 664-683 EduCare ... 873 fibrocystic changes ... 56, 86, 87 fibrocystic disease ... 86 Survivorship education, post-treatment ... 779 Programs...... 684-703 financial barriers ... 353 egg freezing ... 548 Navigation Program financial benefits of BHN ... 839 elephantiasis ... 673 Organization...... 704-747 fine needle aspiration (FNA) ... 125 ellence ... 488 Breast Center empathy ... 351, 357 fistula ... 80 Marketing...... 748-783 employment discrimination ... 684 flesh-eating bacteria ... 93 EduCare...... 784-795 employment issues ... 684 follow-up care end-of-life decisions ... 734 ASCO recommendations ... 523 end-of-life discussion ... 730 frozen shoulder ... 405 energy level ... 681 fungal infection ... 85 environmental pollution ... 57 furuncles ... 85 epigastric perforator ... 436

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 hidradenitis suppurativa ... 85 high fat diet ... 186 G histological grade ... 478 Page Directory galactocele ... 89 history Navigator Role...... 1-31 galactography ... 216 breast conserving surgery ... 35 Historical Overview...... 32-42 galactorrhea ... 188, 215, 225 breast reconstruction ... 35 Statistics and Risk gamma-linolenic acid (GLA) ... 188 breast surgery ... 35 Factors...... 43-60 gauze pad test ... 209 chemotherapy ... 36 Anatomy and gelatinous carcinoma ... 315 mammography ... 36 Physiology...... 61-72 gender ... 52 radiation therapy ... 36 Benign Breast gene profiles ... 491 Conditions...... 73-95 treatment progression timeline ... 37 generalized anxiety disorder (GAD) ... hormonal therapy ... 493, 505 Diagnosis of Breast 665 Disease...... 96-166 hormone replacement ... 55 genetic testing Breast Pain...... 167-192 hormones ... 244, 266 benefits ... 643 Breast Discharge...... 193-209 Horner’s Syndrome ... 572 cost ... 648 hot flashes ... 251, 268, 599 Male Breast Disease...... 210-224 procedure ... 646 hot flash management ... 618 Hormones and Breast results ... 648, 650 Disease...... 225-275 HydroMARK microclip ... 128 genomics ... 491 Understanding Breast hyperesthesia ... 405 gigantomastia ... 80 Cancer...... 276-307 hyperplasia ... 100 gynecomastia ... 228 Navigator as Coach...... 308-349 hypertensive medications ... 230 adult ... 231 Surgical Decisions...... 350-381 hypertrophy ... 80, 229 medication-induced ... 231 hypothyroidism ... 188, 215 Breast Reconstruction...... 382-430 medications affecting breast ... 240 Breast Cancer pubertal ... 230 Treatment...... 431-475 treatment ... 232, 239 I Pregnancy and Breast Cancer...... 476-487 I-GAP ... 439 Fertility Issues...... 488-499 imaging dense breasts ... 110 H Recurrent Breast implants ... 422, 448, 472 hair dye ... 56 Cancer...... 500-520 complication rates ... 426 halaven ... 494 Sexuality After Breast gummy bear ... 423 halstead radical mastectomy ... 397 Cancer...... 521-564 imaging ... 428 hamartoma ... 100 Hereditary Breast risks ... 425 Cancer...... 565-587 hands-on therapy ... 499 saline ... 423 heart disease ... 604 Survivorship silicone ... 423 Challenges...... 588-628 hemangioma ... 100 surgical techniques ... 423 Spiritual Needs...... 629-645 hematoma ... 89, 190, 403 incidence ... 45 Terminal Patient...... 646-663 HER-2 receptors ... 328 incisional biopsy ... 131 herbal products ... 185 Support Programs...... 664-683 infant breast enlargement ... 229 herbal therapy ... 499 Survivorship infant hyperplasia ... 69 Programs...... 684-703 herceptin ... 490 infections ... 85 Navigation Program hereditary breast cancer ... 53, 634 inferior gluteus flap ... 454 Organization...... 704-747 additional resources ... 661 infertility ... 546 Breast Center assessment tools ... 645 infertility symptoms ... 553 Marketing...... 748-783 preliminary assessment ... 644 infiltrating lobular carcinoma ... 313 EduCare...... 784-795 questionnaire, Myriad ... 655 inflammatory carcinoma ... 319 red flags ... 642 inframammary ridge ... 82 role of genes ... 638 in situ breast cancer ... 45, 306 transfer of mutated genes ... 639 insomnia ... 251, 605 hereditary mutation ... 304, 636 interdisciplinary conference ... 797, 858, herpes zoster ... 86 862, 863

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 intrabeam radiation ... 496 staging ... 673 invasive breast cancer ... 45, 306 treatment ... 675 invasive cancer grading ... 324 lymphedema education ... 677 Page Directory invasive ductal carcinoma ... 311 lymph fluid ... 671 Navigator Role...... 1-31 in vitro fertilization ... 548 lymph node metastasis ... 572 Historical Overview...... 32-42 involution ... 80 lymph nodes ... 72, 671 Statistics and Risk iodine deficiency ... 188 lymph node status ... 324 Factors...... 43-60 ixabepilone ... 494 lyphatic system ... 671 Anatomy and ixempra ... 494 Physiology...... 61-72 Benign Breast M Conditions...... 73-95 K macrocalfications ... 117 Diagnosis of Breast Disease...... 96-166 kadcyla ... 494 macrocysts ... 80 Breast Pain...... 167-192 Klinefelter’s syndrome ... 53 male breast cancer ... 46, 233 Kneece, Judy C. ... 873 peer support ... 236 Breast Discharge...... 193-209 red flags ... 234 Male Breast Disease...... 210-224 treatment ... 235 Hormones and Breast Disease...... 225-275 L treatment options, NCI ... 241 lactation ... 70 male breast disease ... 228 Understanding Breast Cancer...... 276-307 lactiferous sinus ... 68 malpractice ... 107 Navigator as Coach...... 308-349 lapatinib ... 494 MammaCare breast exams ... 108 Surgical Decisions...... 350-381 laser imaging ... 122 MammaPrint ... 491 latissimus dorsi flap ... 437, 457 mammary duct ectasia ... 213 Breast Reconstruction...... 382-430 lesions ... 100 mammary line ... 83 Breast Cancer Treatment...... 431-475 letter, samples mammography ... 109 BHN introduction ... 817 3-D ... 114 Pregnancy and Breast Cancer...... 476-487 breast center survey ... 869 BI-RADS reports ... 115 Fertility Issues...... 488-499 evaluation of BHN services ... 819 limitations ... 109 Recurrent Breast explanation of BHN role ... 818 Mammography Quality Standards Act Cancer...... 500-520 life review ... 733 (MQSA) ... 109 Sexuality After Breast patient tips ... 115 Li-Fraumeni syndrome ... 53 Cancer...... 521-564 lipoma ... 97, 100 post surgery ... 679 Hereditary Breast liver metastasis ... 570 reporting guidelines ... 116 Cancer...... 565-587 living wills ... 746 mammography results ... 117 Survivorship lobes ... 68 questionable signs ... 117 Challenges...... 588-628 lobular carcinomas ... 312 mammoplasty ... 429 Spiritual Needs...... 629-645 lobular involution ... 80 MammoSite ... 495 Terminal Patient...... 646-663 margins ... 324 lump ... 80 Support Programs...... 664-683 lumpectomy ... 395 marketing breast center ... 842, 865 Survivorship discharge instructions ... 418 ideas ... 847 Programs...... 684-703 lung metastasis ... 569 Maslow’s Hierarchy of Needs ... 344 Navigation Program lymphangiosarcoma ... 673 massage guidelines ... 698 Organization...... 704-747 lymphatic drainage ... 76 mastectomy ... 397 Breast Center lymphatic invasion ... 328 discharge instructions ... 408 Marketing...... 748-783 lymphatics, breast ... 72 prophylactic ... 58, 399 EduCare...... 784-795 lymphatic system ... 72 types ... 397 lymphedema ... 671 mastitis ... 80, 92, 100, 189 characteristics ... 672 lactational ... 92 incidence ... 672 non-lactational ... 92 patient instructions ... 674 mastopexy ... 430 prevention ... 674 medullary carcinoma ... 317

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 menopausal symptoms chart ... 265 navigator role ... 4 menopausal symptoms treatment ... 267 avoiding burnout ... 363 menopause ... 250 outreach navigator ... 5 Page Directory chemotherapy-induced ... 594 overview ... 4 Navigator Role...... 1-31 physiological changes ... 596 screening navigator ... 5 Historical Overview...... 32-42 menstruation ... 55 setting boundaries ... 363 Statistics and Risk metastasis ... 302, 480, 568 survivorship navigator ... 6 Factors...... 43-60 bone ... 568 NCCN Treatment Guidelines ... 481 Anatomy and bone marrow ... 570 necrosis ... 324, 403, 442 Physiology...... 61-72 brain ... 569 needle localization ... 130 Benign Breast Conditions...... 73-95 carcinomatous meningitis ... 569 neoadjuvant chemotherapy ... 488 liver ... 570 neurofibroma ... 100 Diagnosis of Breast Disease...... 96-166 lung ... 569 neurofibromatosis ... 85 Breast Pain...... 167-192 lymph node ... 572 newsletter ... 797 Breast Discharge...... 193-209 spinal cord ... 568 night sweats ... 251, 600 metastatic cancer ... 321 nipple and areola ... 65 Male Breast Disease...... 210-224 metastatic process ... 329 nipple bleeding ... 225 Hormones and Breast Disease...... 225-275 methotrexate ... 488 nipple discharge ... 80 Understanding Breast microcalcifications ... 117 nipple retraction ... 80, 103 Cancer...... 276-307 microclip placement ... 128 nipple-sparing mastectomy ... 399 Navigator as Coach...... 308-349 microdochectomy ... 217 node ... 480 Surgical Decisions...... 350-381 milk production ... 70 nodularity ... 80, 82 mindy-body therapy ... 499 noncyclic pain ... 189 Breast Reconstruction...... 382-430 mitotic count ... 327 Nottingham Combined Histological Grade Breast Cancer Treatment...... 431-475 mitotic inhibitors ... 488 ... 324, 478 Pregnancy and Breast molecular breast imaging (MBI) ... 122 nuclear grade ... 323 Cancer...... 476-487 Mondor's Disease ... 95 numbness ... 404 Fertility Issues...... 488-499 Mondor’s Syndrome ... 190 nutrition ... 680 nutrition evaluation ... 699 Recurrent Breast Montgomery’s Glands ... 66 Cancer...... 500-520 mood swings ... 601 Sexuality After Breast mucinous carcinoma ... 315 O Cancer...... 521-564 multicentric ... 323 Hereditary Breast multidisciplinary conference ... 850 obesity ... 55 Cancer...... 565-587 multifocal ... 323 oncoplastic surgery ... 400 Survivorship musculoskeletal pain ... 191 Oncotype DX ... 491, 508 Challenges...... 588-628 mutation ... 303 oophorectomy, prophylactic ... 58 Spiritual Needs...... 629-645 myths ... 58 orifices, duct ... 66 Terminal Patient...... 646-663 orifices, nipple ... 66 Support Programs...... 664-683 osteoporosis ... 603, 619 Survivorship N out-migration ... 133 Programs...... 684-703 nab-paclitaxel ... 494 ovarian retrieval and transplantation ... Navigation Program nadir ... 513 548 Organization...... 704-747 NAPBC Standards ... 28 oxytocin ... 70 Breast Center National Accreditation Program for Marketing...... 748-783 Breast Centers (NAPBC) ... 8 EduCare...... 784-795 nausea and vomiting ... 517, 605 P navigation software ... 811 paclitaxel ... 488 navigator ... 5 Paget Disease ... 85, 214, 314 navigator reporting ... 798 painful intercourse ... 599 palpable mass ... 139 papillary carcinoma ... 214, 316

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 papilloma ... 97 treatment decisions ... 534 papillomatosis ... 100 ultrasound ... 531 partial breast radiation ... 495 prevention, breast cancer ... 58 Page Directory pathology reports ... 322, 331 progesterone ... 69, 246 Navigator Role...... 1-31 pathology tumor studies ... 326 progestin ... 55 Historical Overview...... 32-42 patient program organization ... 773, 793 Statistics and Risk answering difficult questions ... 358 advisory team ... 793 Factors...... 43-60 connection obstacles ... 350 community outreach ... 794 Anatomy and contact frequency ... 349 monitoring outcomes ... 822 Physiology...... 61-72 dismal test results ... 358 navigator resources ... 824 Benign Breast Conditions...... 73-95 initial appointment ... 347 new center opening ... 846 initial interview ... 350 planning guidelines ... 801 Diagnosis of Breast Disease...... 96-166 interview tips ... 362 signature event ... 794 Breast Pain...... 167-192 relationship guidelines ... 349 prolactin ... 69 Breast Discharge...... 193-209 telephone contact ... 349 proliferative lesions ... 54 treatment barriers ... 353 prosthesis selection ... 683 Male Breast Disease...... 210-224 patient contact record psychological adjustment ... 665 Hormones and Breast Disease...... 225-275 monthly ... 815 psychological barriers ... 353 Understanding Breast weekly ... 813 psychological distress ... 665 Cancer...... 276-307 patient education record ... 816 puberty ... 69 Navigator as Coach...... 308-349 patient perspective ... 343 punch biopsy ... 125 Surgical Decisions...... 350-381 patient relationship ... 346 pectoralis spasms ... 405 Breast Reconstruction...... 382-430 perforator flap ... 435 R Breast Cancer Treatment...... 431-475 perimenopause ... 249 radial scar ... 98, 100 Pregnancy and Breast personal cancer history ... 54 radiation induced angiosarcoma ... 573 Cancer...... 476-487 personal care barriers ... 353 radiation therapy ... 483, 495 Fertility Issues...... 488-499 PET scan ... 123 after mastectomy ... 483 Recurrent Breast complications ... 521 phlebitis ... 95, 190, 405 Cancer...... 500-520 phyllodes tumor ... 98, 100 reconstructed breast ... 441 Sexuality After Breast physical activity ... 56 types ... 495 Cancer...... 521-564 screening ... 701 raloxifene ... 597 Hereditary Breast pinched nerve ... 191 range of motion ... 675 Cancer...... 565-587 pituitary tumor ... 215 reconstruction ... 431, 483 Survivorship postoperative care ... 402 additional resources ... 473 Challenges...... 588-628 postoperative discharge ... 392 autologous ... 434 Spiritual Needs...... 629-645 post surgical instructions ... 391 comparison of procedures ... 446 Terminal Patient...... 646-663 post-traumatic stress disorder (PTSD) ... complications and risks ... 447 Support Programs...... 664-683 665 delayed ... 432 Survivorship pregnancy ... 69 flap types ... 461 Programs...... 684-703 pregnancy and breast cancer ... 530 immediate ... 432 Navigation Program additional resources ... 543 nipple and areola ... 439, 459 Organization...... 704-747 biopsy procedures ... 532 recurrent breast cancer ... 486, 559 Breast Center breast MRI ... 531 clinical pictures ... 571 Marketing...... 748-783 chemotherapy ... 537 detection ... 562 EduCare...... 784-795 imaging ... 531 diagnostic work-ups ... 565 mammography ... 531 EduCare research ... 576 NCI Summary ... 541 emotional experience ... 560 pregnancy after breast cancer ... 539 local recurrence ... 486 surgical guidelines ... 536 navigator guidelines ... 574

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 patient support ... 560 size, breast ... 65 statistics ... 562 skin changes ... 103 survival ... 564 skin markers ... 111 Page Directory systemic recurrence ... 486 Beekley ... 111 Navigator Role...... 1-31 treatments ... 565 skin-sparing mastectomy ... 397 Historical Overview...... 32-42 types ... 562 smoking ... 55 Statistics and Risk religious barriers ... 354 sodium ... 186 Factors...... 43-60 religious beliefs ... 718, 720 somatic mutation ... 304 Anatomy and religious influences ... 717 specialty clinics ... 853 Physiology...... 61-72 revenue breast discharge assessment ... 855 Benign Breast Conditions...... 73-95 down-stream revenue ... 839 breast pain assessment ... 854 financial benefits ... 840 help line ... 853 Diagnosis of Breast Disease...... 96-166 financial benefits of BHN ... 839 high risk assessment ... 855 Breast Pain...... 167-192 spin-off revenue ... 840 SPIKES Model ... 356 Breast Discharge...... 193-209 risk spinal cord metastasis ... 568 absolute risk ... 49 spiritual needs ... 709, 725 Male Breast Disease...... 210-224 lifetime ... 46 sporadic breast cancer ... 636 Hormones and Breast Disease...... 225-275 relative risk ... 49 staging abbreviations ... 479 Understanding Breast risk assessment form ... 136 statistics ... 45 Cancer...... 276-307 risk factors ... 49, 52 stress ... 80 Navigator as Coach...... 308-349 stress response: fight or flight ... 385 Surgical Decisions...... 350-381 striae ... 82 S suffering ... 711 Breast Reconstruction...... 382-430 SAVI ... 495 support group Breast Cancer Treatment...... 431-475 scar ... 403, 439 breast cancer ... 761 Pregnancy and Breast sclerosing adenosis ... 91, 100, 213 formation ... 762 Cancer...... 476-487 seatbelt use ... 404 men ... 756 Fertility Issues...... 488-499 sebaceous cyst ... 85 metastatic ... 764 Recurrent Breast second opinions ... 408 planning ... 766 Cancer...... 500-520 sentinel node biopsy ... 396, 483 support partner ... 753 Sexuality After Breast seroma ... 403 support programs ... 796 Cancer...... 521-564 sex drive ... 603 support referrals ... 796 Hereditary Breast sexual education surgery ... 483 Cancer...... 565-587 chemotherapy impact ... 594 surgical arm protection ... 675 Survivorship patient discussion ... 591 surgical decisions ... 388 Challenges...... 588-628 patient views ... 589 surgical dress rehearsal ... 391 Spiritual Needs...... 629-645 sexual functioning surgical instructions ... 391 Terminal Patient...... 646-663 identifying barriers ... 590 surveillance ... 498 Support Programs...... 664-683 identifying causes of problems ... 593 survival rates, 5 year ... 506 Survivorship medications affecting functioning ... survival statistics ... 47 Programs...... 684-703 605 survivorship care plan ... 773 Navigation Program sexuality after breast cancer ... 584 ASCO ... 775, 783 Organization...... 704-747 sexuality cancer resources ... 631 CoC guidelines ... 777 Breast Center Marketing...... 748-783 sexual response cycle ... 606 NCI ... 786 male vs female arousal comparison ... patient delivery ... 777 EduCare...... 784-795 607 survivorship guidelines, EduCare ... 9 S-GAP ... 439, 463 survivorship program, additional shape, breast ... 65 resources ... 790 shingles ... 86, 191 survivorship program development ... shoulder bursitis ... 192 773, 778 SIEA ... 437 syphilis of breast ... 86

BREAST HEALTH NAVIGATOR MANUAL Revision Date: 01/2016 EduCare Inc. © 2016 T X Page Directory tamoxifen ... 493, 597 xeloda ... 494 Navigator Role...... 1-31 Tanner I-V ... 69 Historical Overview...... 32-42 TAP ... 438, 466 Statistics and Risk taxol ... 488 Factors...... 43-60 taxotere ... 488 Anatomy and terminal patient ... 728 Physiology...... 61-72 additional resources ... 747 Benign Breast testosterone ... 247, 603 Conditions...... 73-95 Tietze’s Syndrome ... 191 Diagnosis of Breast tinea versicolor ... 86 Disease...... 96-166 TNM staging ... 328, 507 Breast Pain...... 167-192 TRAM flap ... 435, 469 Breast Discharge...... 193-209 transportation barriers ... 353 Male Breast Disease...... 210-224 treatment selection factors ... 478 Hormones and Breast triple negative breast cancer ... 328 Disease...... 225-275 triple test ... 124 Understanding Breast trust ... 713 Cancer...... 276-307 tubular carcinoma ... 318 Navigator as Coach...... 308-349 tumor ... 479 Surgical Decisions...... 350-381 tumor location ... 322 Breast Reconstruction...... 382-430 tumor size ... 322 Breast Cancer tykerb ... 494 Treatment...... 431-475 Pregnancy and Breast Cancer...... 476-487 U Fertility Issues...... 488-499 ultrasound ... 123 Recurrent Breast post-radiation ... 679 Cancer...... 500-520 ultrasound guided core biopsy ... 126 Sexuality After Breast Cancer...... 521-564 underwire bras ... 56 urinary tract ... 599 Hereditary Breast Cancer...... 565-587 Survivorship V Challenges...... 588-628 Spiritual Needs...... 629-645 vacuum-assisted biopsy ... 126 Terminal Patient...... 646-663 Vagifem ... 599 Support Programs...... 664-683 vaginal dryness ... 598 Van Nuys Prognostic Index Score ... 478 Survivorship Programs...... 684-703 vascular invasion ... 328 Navigation Program vascular system ... 599 Organization...... 704-747 Breast Center Marketing...... 748-783 W EduCare...... 784-795 weight gain ... 604, 680 weight-lifting guidelines ... 677 weight loss ... 700 Women's Health Initiative (WHI) Study ... 255