Certain factors, which increase a woman’s risk of breast cancer, which can be altered include:
Women who use products, which contain oestrogen, or progesterone which are found in oral contraceptives or Hormone Replacements Therapy (HRT).
High levels of oestrogen and progesterone in some cases can promote the growth of breast cancer cells. The effects are not large and may disappear within a decade of giving up hormone use Henderson et 1984,Dolinsky C 2000.
Obesity is also associated with a two-fold increase among postmenopausal women; this has been linked with high intake of meat and dairy fat.
Regular alcohol consumption increase risk by 40%. Denton S 1996,Willet WC 2001.
All these risk factors are based on probabilities and even someone without any risk factor may develop breast cancer Willet W C, 2001.
The individual cannot control the most important risk factors for the development of breast cancer. Among high-risk women referral to a breast care team for counselling can reduce anxiety and regular surveillance may improve the chance that breast cancer will be detected at an early stage and effecting treatment at this stage enhances chances of cure. Prophylactic mastectomy should be available for women who are in the high-risk category. Such women should have counselling before any decision is made and should be given opportunities to discuss all aspects of operation including reconstruction Dixon M C, 2000, NHS manual update 2002.
Trials of chemoprevention using Tamoxifen found a highly significant reduction in breast cancer incidence in the United States. European trials have yet to show any benefit. However tamoxifen is associated with adverse effects including hot flushes vaginal symptoms and sexual problems and in women over 50 years endometrial cancer, pulmonary embolism and cataracts NHS manual update 2002.
There are a few risk factors that may be modified by a woman that potentially could influence the development of breast cancer. If possible, a woman should avoid long term hormone replacement therapy and contraceptive pills. Avoid weight gain through exercises and proper diet and limit alcohol consumption to one drink a day on even less. Try to have children before the age of 30 and breast feed the babies.
During breast feeding the anterior pituitary gland is stimulated and produces more prolactin hormone. High circulating levels of prolactin inhibits gonadotrophin hormone release and prevents ovulation. Therefore decreased levels of oestrogen’s, which are through to cause growth of breast cancer cells. So when women who do not breast-feed have high levels of oestrogen’s circulating throughout Parker J 1994, Lunn et al 1992.
BREAST CANCER SCREENING
Proper screening and early detection are the best weapons in reducing the mortality associated with breast cancer. Breast cancer screening is the practice of investigating apparently healthy individuals with the object of detecting unrecognised disease or people with an exceptionally high risk of developing breast cancer and intervening in ways that will prevent the occurrence of disease or improve the prognosis Farmer and Miller 1983. However other researchers found that a woman who has experienced no signs or symptoms of a possible breast problem comes for routine screening is then given a diagnosis of breast cancer, she may well find it especially hard to accept the diagnosis. Her initial reaction may be that she is going to die. Nevertheless, she will need very skilled counselling to help her come to terms with the diagnosis of cancer and with the change in self image that may result from her surgical treatment Cotton T 1996, Mateau TM 2001.
The Forrest report DHSS 1986 recommended the introduction of a national screening programme after a successful research. Thereafter breast cancer centres were encouraged throughout the country. Screening is offered to women aged 50 to 64 years every three years. The Forest report recognised that if it was to achieve a reduction in mortality by identifying an early stage cancer the programme had to set high standards which included:
. Taking the mammograms
. Identifying and assessing abnormalities
. Follow up of women with abnormalities
Screening mammograms are simply x – rays of each breast. Mammograms often detect tumours before they can be felt and they can also identify tiny specks of calcium that could be an early sign of cancer. Recently published research has shown that breast cancer death rates fell by 21.3% in women aged 55 and 69 between1990 and 1998. 30% of this fall was attributed to screening and the rest to treatment improvement and other factors The NHS Cancer Plan, 2000.
Between the ages 20 – 40 every woman should have a clinical breast examination every three years and after 40 years every woman should have a clinical breast examination done annually. A clinical breast examination is done by a health professional to feel for lumps and look for changes in the size or shape of the breast Easton et al., 1993.
Breast self examination costs nothing and consumes a few minutes of our time each month. The returns are rewarding, it can help transform a potentially life threatening disease (breast cancer) into a manageable health episode. Very few women practice breast self examination because they fear they may detect a lump. Many women fear changes in their body image and pain. The woman who practices Breast self examination is one who is not frightened of the future. She wants to be in control of her life and to assure her own good health. She has appositive mind by nature and believes that facing up to risks and problems is better that pretending that they don’t exist. She will prefer employing preventive and coping strategies to accept what fate deals out. M Baun 1999 points out that the early stages of breast cancer may not have any symptoms. This is why it is important to follow breast self examination and screening recommendations.
As a tumour grows in size it can produce a variety of symptom which include:
- Lump or thickening in the breast or underarm.
- Change in size or shape of the breast.
- Nipple becomes inverted i.e. turning inwards.
- Dimpling of the skin.
- Bleeding or discharge from the nipple.
- Redness or scaling of the skin or nipple
It has been recommended by the Department of Health that urgent referral within 2 weeks should be done once the above symptoms are seen NHS Manual update 2002.
Conditions which do not require urgent referral are:
- Discrete lump in young women less than 30 years old.
- Abscess
- Persistently refilling or recurrent cysts.
- Pain not responding to simple measures.
An observation made at the Breast Cancer clinic was that once a patient has symptoms suggestive of breast cancer or has an abnormal screening mammogram they are sent for a Diagnostic mammogram, which is another set of x rays which are more complete with close ups on the suspicious areas.
Ultrasound is also done; this is a painless procedure, which uses high frequency sound waves to outline the suspicious areas of the breast. It can distinguish between benign and malignant lesions. Depending on the result as the mammograms and ultrasound the doctor may recommend that a Biopsy should be done.
A biopsy is the only way to know for sure if one has cancer, because cells are taken from the lesions and are examined under a microscope. These are different types of biopsies; they differ on how much tissue is removed. Some biopsies use very fine needle known as Fine Needle Aspiration (FNA) involves passing a thin needle into the breast lump and withdrawing tissue for examination. Some use a thicker needle known as Needle Core Biopsy. It is done under local anaesthesia and a thick needle is done to retrieve some tissue. The advantages are a greater accuracy in diagnosis and possibility of doing more tests on the samples, which cannot be done with FNA.
Some require a SURGICAL BIOPSY, which is done under general or local anaesthesia and involves a small incision so that some tissue or a whole lump be removed and examined under microscope. Once the tissue is removed a pathologist reviews the specimen and can declare it cancerous or not. If it is cancerous the pathologist will characterise by what type of tissue it arose from, how abnormal it looks ( known as grading) and if the entire lamp was excised or cancer cells left at the borders. A test is also done for the presence of oestrogen and progesterone in order to guide treatment and offer insight into prognosis Carlson 1991.
There is a strong evidence that triple assessment increases the accuracy and reduces overall cost of diagnosis when compared with selective use of component tests NHS Manual update, 2002.
Accurate clinical staging is important because this helps in management and prognosis. The staging systems are based on clinical size and extent of invasion of the tumour Baum, M 1999.
STAGE 0 ( called carcinoma in - situ)
Lobular carcinoma in – situ refers to abnormal cells lining a gland in the breast.
Ductal carcinoma in – situ (DCIS) refers to abnormal cells lining the duct..
STAGE 1
Early stage breast cancer where the tumour is less than 2cm across and has not spread beyond the breast.
STAGE 2
Early stage breast cancer where the tumour is less than 2cm and has spread to the lymph nodes under the arm or the tumour is between 2 – 5cm (with or without spread to the lymph nodes under the arm) or the tumour is 5cm and has not spread outside the breast.
STAGE 3
Locally advanced breast cancer where the tumour is more than 5cm across and has spread to the lymph nodes under the arm, near the breast bone or other tissues near the breast.
STAGE 4
Metastatic breast cancer where the cancer has spread outside the breast to other organs of the body .
( Alexander, F et al.1994, Baum, M 1999, Denton, S 1996. )
According to Baum 1999 breast cancer has been graded into three grades. This refers to the appearance of cancer cells on microscope.
Grade 1 – low grade
Grade 2 – moderate grade
Grade 3 – high grade
Knowing the extent of the cancer (stage) and the grade helps the doctors to decide on the appropriate treatment.
TREATMENT APPROACHES
West N and Brown H, cited in Denton S, 1996 that almost all women with breast cancer will have some type surgery in the course of their treatment.
The purpose of surgery is to remove as much of the breast cancer as possible and there are different ways that the surgery can be carried out. Some women will be candidates for what is known as Breast Conservation Therapy (BCT). This is recommended for women with stage 1 and 2 breast cancer. In BCT surgeons perform a LUMPECTOMY which means removing the tumour with a little bit of breast tissue around it but do not remove the entire breast. BCT always needs to be combined with radiation therapy to make it an option for treating breast cancer. Fisher et al 1989 demonstrated that women who did not receive radiotherapy following conservative therapy had higher local recurrence rates 30% compared with those who had received radiotherapy 5%.
Sometimes PARTIAL MASTECTOMY is done which involves removing a larger part of the breast tissue.(but not the whole breast). This needs to be combined with radiotherapy as well. The advantages of BCT and partial mastectomy are that the shape of the breast is preserved, leaves a small scar, there is little change in body image so that a reconstruction or prosthesis may not be required later on. The disadvantages are that some women worry that the cancer has not been removed because some breast tissue is left, and some may have long term side – effects of radiotherapy.
More advanced breast cancer are usually treated with a MODIFIED RADICAL MASTECTOMY; which means removing the entire breast and dissecting the lymph nodes under the arm. The advantages are that radiotherapy will not be needed later and some women feel that if all the breast tissue is removed there is less likelihood of the cancer coming back. They may have immediate reconstruction to form a new breast to achieve the desired appearance. The biggest disadvantage is that some women find it very distressing because of the change in body image.
Fallowfield et al 1990 found that women whose surgeons offered a choice showed less depression than those treated by surgeons who offered no choice. It should be noted that that surgery also depends on the size of the cancer, proximity of the cancer and the presence of multifocal disease. Patients should be informed of all potential risks, benefits and implications for further treatment.
Despite the fact that tumours are removed surgically, there is always a risk of recurrence because there may be microscopic cancer cells that has spread to distant sites in the body Verena T, 1996. In order to decrease a patients risk of recurrence many breast cancer patients are offered CHEMOTHERAPY. This is the use of anti cancer drugs that go throughout the entire body. The higher the stage of cancer, the more important it is that one receives chemotherapy.
However the option of chemotherapy should be offered to patients with breast cancer and the can decide if the potential benefits out weigh its side effects in their own particular case. Sometimes patients have a recurrence in their cancer or present in stage 4 with disease outside their breast. These patients need chemotherapy and a variety of different agent may be tried till a response is achieved. Chemotherapy may be given before surgery although this is usually reserved for very advanced cancers that need to be shrunken before operation (Cotton, 1999).
Breast cancer patients may also receive RADIATION THERAPY. The therapy uses high energy rays (similar to x rays) to kill the cancer cells. The treatment only takes a few minutes and is painless but there is evidence of increased toxicity with higher (nausea) doses. Radiation therapy is used in all patients who receive breast conversation therapy. It is also recommended for patients after mastectomy if they had large tumours, involvement of lymph node or positive margins after surgery. Radiation is also important in reducing the risk of local recurrence and is often offered in more advanced cases to kill tumour cells that may be leaving in lymph nodes Denton, S 1996
Another treatment that is coming up is hormone treatment, which has been found to produce significantly better outcomes in women with oestrogen receptor positive tumours than in those whose tumours are receptor negative. The treatment has recently attracted a lot of interest in cancer treatment and further studies on the efficacy of the treatment are still underway. Before the hormone is administered to patients, pathologists examine the tumour specimen to find out if it is secreting oestrogen or progesterone receptors. Patients whose tumours are expressing these hormones are candidates for the therapy with an oestrogen-blocking drug called TAMOXIFEN. According to NHS manual update in 2002 tamoxifen reduced recurrence rate for breast cancer from 13.4 to 8.2 over 5 years in women who had DCIS. However, weight gain, hot flushes and vaginal discharge have been noted in women taking the therapy. Other but rare side effects have included blood clots and strokes (NHS manual update, 2002). The patients need to remember that chances of having recurrence of breast cancer are higher than chances of having serious side effects with tamoxifen. Hormone manipulation can also be achieved destruction or removal of ovaries that produces the oestrogen hormone. This has been shown to be as effective as chemotherapy (NHS manual update, 2002).
THE PSYCHOLOGICAL AND SOCIAL IMPACT OF BREAST CANCER
Learning that cancer has been diagnose can have devastating effects on the patients and her family. The key to breaking bad news is to try to slow down the effects of transition from a patient’s perception of being well to a realisation that she has a life threatening disease. Evidence shows that breaking the news abruptly will disorganise the patient psychologically and impair adaptation or provoke denial (Maguire & Faulkner, 1988). The response to diagnosis of cancer has also been associated with persons search for meaning as to why she had cancer (O’connor, et al, 1990). Faith and social support were found to assist individuals in this search and the nurse most familiar with the patient was found to be in the best position to help. It is also recommended that newly diagnosed breast cancer patients should be clearly advised that treatment is not something that is quickly dispensed but something that involves a combination of therapies over a period of time. Therapies that may include the removal of breast but as Fallowfield, et al, 1990 says an immediate effect of breast cancer is threat to patient’s life and health; a threat to life being greater than loss breast. In a review of literature, Morton presented the findings of Maguire 1985 who noted that patients who received a diagnosis of breast cancer may feel uncertainty, helplessness, loss of meaning, failure, stigma and isolation (Morton 1996). Morton 1996 went on to identify other feelings and reactions, which included denial, anger, blame, despair and depression. It is difficult to predict how patients will respond to cancer diagnosis, each individual will respond in a different way which will be determine by things like cultural background, religion, support networks and quality of rapport with the health care professional (Franklin & Smith 1994; Morton 1996). In this situation the nurse can emerge as the key player by establish an open intimate relationship with the patient. However, Parathian and Taylor 1993 points out that nurses have not really come to terms with dealing with patients who have received bad news and there is a case for more intensive training in communication skills which has been supported. Psychological support should be available at every stage to help patients and their families cope with the effects of the disease. Up to one third of women develop severe anxiety or depression illness within a year of diagnosis (Dixon 2000). Patients should be offered clear objective full information about their condition in both verbal and written form.
PORTIFOLIO OF LEARNING OF EVIDENCE
CRITICAL INCIDENT ANALYSIS
CHANGE IN BODY IMAGE
Brenda (pseudonym) is 60 years old and weighs 70 kg, lives with a partner weighs has a thirty four year old son. She is a non-smoker and takes wine and takes wine and beer occasionally. She has never been on Hormone Replacement Therapy and is not allergic to any food or medicines. She takes bendrofluazide for a raised blood pressure and Timoptol for glaucoma. There is no history of cancer in her family and she did not have any breast problems. She attended her routine breast screening in mid September 2002. Several mammograms were taken of both her breast, the radiologist read the films and her left breast showed areas of calcifications. Brenda was referred to a breast specialist consultant. A further range of diagnostic investigations was done which included ultrasound and surgical biopsies were done under general anaesthesia and left breast cancer was confirmed.
The consultant explained to Brenda about the diagnosis in the presence of the breast care nurse. Despite all the explanation about the disease and counselling by the Breast care nurse Brenda was overwhelmed. She was very upset and was shouting at everyone. The agreed management was left mastectomy and insertion of implant.
On the day of admission Brenda was so upset and angry. She was reassured that it is understandable that she is deeply upset by many aspects of her illness and there was no need to feel guilty about her angry thought and irritable mood.
Brenda did not want to accept that she had cancer and that one of her breast was going to be removed. She was scared by the disfigurement that would be caused by the mastectomy. She was reassured by the consultant and Breast care nurse that an implant would be inserted and would still be as attractive as ever but Brenda said “implant will never be the same as her own breast and cried that the candle is gone.” This made it very difficult to nurse Brenda because she was in a Denial Phase.
People without any risk factors can still get breast cancer Denton S 1996, as in Brenda’s case. Though screening is becoming a growing part in the Health care system it should be remembered that a positive result is usually received with negative feelings Quillam 1992, Marteau 1990, Posner and Vessey 1988.
Our body image is our perception of our own appearance, which might be quite different from our actual physical appearance. This can be seriously altered by breast cancer treatment especially if a woman’s self esteem is tied up with her appearance sexual identity Alexander 1994, Fawcett et al 1990, Maguire 1988. In more descriptive terms “body image” forms part of our total self-concept and as such can have enormous impact on psychological, sociocultural and physical concepts of self Blackmore citied in Alexander et al 1994. Problems with altered body image commonly present after all kinds of Brest surgery, which include biopsies, lumpectomies and mastectomies. Mastectomies causes the severe change Reaby 1998. Thus it would become quite clear that confronting an altered body image i.e. following mastectomy will be one of the primary post operative tasks of the patient. Individuals will of course deal this with differently and therefore nursing is dependent on patient reaction.
Brenda had three drains which were removed on the second and third day post operatively. She did not want to look on her wound on hear the word “mastectomy”.
Although a woman knows her breast is gone it may take some time to assimilate Maguire and Faulkner 1998, Franklin and Smith 1994. Some acceptance in altered body image include when the patient starts to look at the area , takes over responsibility of care and begins to ask questions about caring for the area Costello 1990 O’Brien 1998 Moron et al 1985. The woman who delays in looking at her wound, is afraid to touch the area or sees no information about self care may develop problems in relation to altered body image Maguire 1998, Denton 1996. Body image disorders require physical and emotional attention. It is important to recognise that the patient is experiencing a loss with regard to her health and body image. Brenda was encouraged to discuss feelings with the partner who was very who was very supportive throughout her stay in hospital. She was also encouraged to express and explore feelings concerning cancer diagnosis and breast loss.
CONCLUSION
The diagnosis of cancer can be very traumatic and the response to such a diagnosis is varied and unpredictable. Mastectomy can cause a woman to experience some real difficulties in the area of self esteem and body image. The emphasis of nurses and patients working together, helps patients to cope better with breast surgery.