Special Issues in Breast Cancer Management
After mastectomy, some women elect to have reconstructive surgery, which provides considerable psychological benefit. Sup-port groups and classes provide education and peer support for patients who are candidates for and interested in breast recon-struction. Some concerns that women may have about recon-structive surgery are cost, safety, and timing—whether to undergo reconstruction immediately (at the time of mastectomy) or delay it (6 months to 1 year after surgery). Cost to the patient may vary depending on her health insurance, but because reconstruction is considered rehabilitative surgery, it is often covered.
In regard to safety, there are the usual surgical risks for infec-tion and reaction to anesthesia, as well as the risk for a cosmetically unsatisfactory result. Reconstructive surgery is contraindicated if a woman has locally advanced, metastatic, or inflammatory breast cancer. Otherwise, most women with either in situ or early-stage breast cancer are candidates for immediate reconstruction. Breast reconstruction does not interfere with systemic treatment, nor does it affect the risk of cancer recurrence.
If a woman decides to have reconstructive surgery at the time of mastectomy, she avoids future surgery, although the total opera-tive time increases. Some women find that immediate reconstruc-tion lessens the feelings of loss and disfigurement. Occasionally, reconstruction cannot be performed because skin and muscles are too tight. Loose, supple skin and subcutaneous tissue with a suffi-cient blood supply contribute to reconstructive success. Some women benefit by waiting until later because initially they are not sure about their choice.
Not all women desire reconstruction, nor are all women candi-dates for reconstructive surgery. In these instances, patients may need information about prostheses (molds made of silicone shaped in the form of a breast) and the names of shops where they can be fitted for a prosthesis. The American Cancer Society’s Reach to Recovery program can provide women with the names and ad-dresses of local establishments where they can be fitted. Women should be encouraged to find a shop that has a comfortable, sup-portive atmosphere and employs a certified prosthetics consul-tant. Generally, medical supply shops are not recommended because they often do not have the appropriate resources to ensure the proper fit of a prosthesis.
Before the patient is discharged from the hospital (following a day-surgery procedure or an overnight hospital stay), the nurse usually provides the patient with a temporary cotton fluff that can be worn until the surgical incision is well healed (4 to 6 weeks). At that time, the woman can be fitted for a prosthesis. Insurance generally covers the cost of a prosthesis and the special bras that hold it in place. Women should be encouraged to wear the pros-thesis because it provides a sense of psychological restoration and wholeness. The prosthesis also assists the woman in resuming proper posture, because it helps to balance the weight of the remaining breast .
Despite current treatment, there has been only a slight overall im-provement in survival for breast cancer patients. Consequently, quality-of-life considerations have become important issues in treatment and recovery. Quality of life is a multidimensional con-struct that includes functional (self-care) status, social and family functioning, and psychological and spiritual well-being. These parameters are important indicators of how well a patient is func-tioning after diagnosis and treatment.
Breast cancer is the most frequently investigated cancer in quality-of-life studies. Early psychosocial studies emphasized that the loss of the breast was the single most important factor in women’s adjustment, especially in Western cultures. Thus, it is not surprising that studies of women’s adjustment to breast can-cer found similar results. A growing body of research, however, indicates that concerns related to uncertainty about the future, day-to-day issues in work and family relationships, and demands of illness are more important factors in adjusting to having breast cancer than the loss of the breast alone. For example, younger women are more vulnerable to issues of psychosocial adjustment than many older women (Hoskins & Haber, 2000). They worry about their jobs and whether they will be able to keep their health care benefits. They are concerned about their work productivity and career advancement (Wonghongkul, Moore, Musil et al., 2000). They face many family concerns related to whether they can have children, whether they will live to see their children grow up, and whether their disease will recur and incapacitate them (Horden, 2000). Middle-aged women worry about their disease in relation to their family and work (Walker, Nail & Croyle, 1999). They also worry about their aging parents and whether they will be able to care for them in the future. They are increasingly concerned about their daughters’ risk for breast can-cer. Older women are more vulnerable to chronic health prob-lems. Living an average of 6 years longer than men, older women face loss of their social circles, must deal with the potential for other diseases, and worry about whether they will have the re-sources to pay for medications.
These concerns are intertwined with the effects of breast can-cer on the family. Studies indicate that up to 35% of families of breast cancer patients experience significant changes in family functioning. More than 25% of children also experience prob-lems related to their mothers’ breast cancer (Hilton, Crawford & Tarko, 2000). In addition, families shoulder substantial costs in caring for family members with advanced breast cancer. These out-of-pocket, unreimbursed expenses include lost wages and salaries and lost opportunities.
When faced with any life-threatening illness, spiritual and ex-istential concerns usually surface. Patients with breast cancer often express the need to talk about the uncertainties of their fu-ture and their hope and faith that they will be able to manage whatever crisis or challenge comes their way.
From 2% to 5% of breast cancers occur in relation to pregnancy (Dow, 2000; Moore & Foster, 2000). The potent hormones re-leased during pregnancy (1,000 times greater than those during a menstrual cycle) stimulate changes in breast tissue (Gemignani Petrek, 1999). Thus, detecting masses is more difficult during pregnancy. An important aspect of health promotion is to en-courage BSE throughout pregnancy.
If a mass is found during pregnancy, ultrasound is the preferred diagnostic method because it involves no exposure to radiation, although mammography with appropriate shielding, fine-needle aspiration, and biopsy may also be indicated. Treatment is basically the same as in other women, although radiation is contraindicated in pregnancy. Some oncologists begin chemotherapy as early as the 16th week of pregnancy because fetal organs are already formed at this point. If systemic treatment is necessary, a cesarean section may be performed as soon as maturation of the fetus allows. If aggressive disease is detected early in pregnancy and chemotherapy is advised, termination of the pregnancy is an issue that some pa-tients must face. If a mass is found while a woman is breastfeeding, she is urged to stop breastfeeding to allow the breast to involute (return to its baseline state) before any type of surgery is performed.
After a woman has completed treatment for breast cancer, she may consider having children. In this case, individual issues must be addressed, including the patient and her partner’s desire for children and family, disease and prognostic concerns, age, fertility and infertility issues, and social, financial, ethical, and quality-of-life issues. Although recommendations vary, most women are advised to wait 2 years before becoming pregnant after completing treatment for breast cancer. Most retrospective studies indicate that pregnancy after treatment for breast cancer does not appear to increase the risk of the disease recurring (Gemignani & Petrek, 1999); however, prospective studies are needed to confirm this. Counseling, providing accurate information, and active listening and caring are important nursing interventions when patients are involved in making difficult personal decisions about treatment options, childbearing, or termination of pregnancy.
The recurrence of breast cancer can be very difficult for patients and family members. Depending on the clinical presentation, progression of the disease can have different meanings. Generally, the longer the disease-free interval, the better the prognosis. Local recurrence either in the affected breast or along the chest wall can be treated, generally with surgery, radiation, or hormonal manip-ulation, although a metastatic disease workup may be in order to look for further evidence of disease. Although metastatic spread of the breast cancer (to the bone, lungs, brain, or liver) cannot be cured, a variety of treatments are available (chemotherapy, radi-ation treatment, hormonal manipulation, or possibly some form of surgery). In some patients, metastases progress very slowly and life functioning is generally not affected, whereas in others the disease progresses rapidly despite treatment, and death from the complications of metastatic disease is inevitable.
The patient with advanced breast cancer is monitored closely for signs that the tumor has recurred or that metastasis has oc-curred. The following studies are conducted to monitor for spread of disease: metastatic x-ray series (chest, skull, long bones, and pelvis); liver function tests (alkaline phosphatase, aspartate amino-transferase [AST] or serum glutamic-pyruvic transaminase [ALT] lactate dehydrogenase); mammogram of contralateral breast and ipsilateral breast (if breast-conserving surgery was originally per-formed); and bone, liver, and brain imaging. In half of all patients with recurrent disease, the cancer reappears locally (on the chest wall or in the conserved breast) or regionally in the remaining lymph nodes, and in one fourth other organs become involved. Bone metastasis is the most common site for spread of the dis-ease, usually involving the hips, spine, ribs, or pelvis. Other sites for metastatic spread are the brain, lungs, and liver.
Regression or relief of the symptoms is the goal of nursing and medical management, and quality of survival time is an important focus of nursing intervention. Assessing the patient’s physical and psychosocial status is a challenge for the nurse. Information from family members and significant others is valuable and should be included in planning care for the patient with advanced disease.
Palliative treatment, if indicated, is also an important aspect of care. Comfort and a pain-free existence, even if the disease cannot be eradicated, enhance the quality of remaining life. Pal-liative surgery may be offered if the patient has a fungating or necrotic tumor in the breast; the most common procedure is a modified radical mastectomy. In patients with bone metastases that cause pain or produce pathologic fractures, reparative or restorative surgery may also be an option; however, this may not be indicated depending on the patient’s medical status and per-sonal choices. Hospice and home health care may be indicated as alternatives. Regardless, specific arrangements for these services should be discussed and planned early, before the actual need arises, to decrease patient distress. Severe anxiety and depression may occur. Treatment modes vary and depend on the patient’s condition, the modalities available, and the patient’s preferences for end-of-life care.