Approach to Care of a Patient with Cancer
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Breast is a modified sweat gland and a distinguishing anatomical feature among mammals with the primary role of producing milk to nourish offspring. The human breast contains 12-15 major breast ducts lined by a layer of epithelial cuboidal cells surrounded by myoepithelial cells. These cells are supported by connective stroma tissue and embedded in fat tissues. The breast epithelium is composed of relatively inner luminal cells required for milk production and an outer layer of myoepithelial cells required for milk ejection (Daniel & Smith, 1999).
Typically, most human breast cancers appear to originate from the normal epithelial cells through a series of changes known as hyperplasias, atypical hyperplasias, in situ carcinomas, invasive carcinomas, and metastatic disease (Allred, Mohsin, & Fuqua, 2001).The progression from normal cells to hyperplasias is resulted by unregulated proliferation. The characteristics of atypical hyperplasias are the alterations of cell adhesion and polarity. In situ carcinomas are characterized by increased growth and distinct histological and biological diversity compared to precursor cells. The transition from in situ carninomas to invasive carcinomas is defined by the invasion of surrounding stroma. Finally, metastasis results from the spread of disease to other sites in the body. Depending on the onset of metastasis, treatment and prognosis values are reduced.
Breast cancer accounts for 23% of all cancers diagnosed among women worldwide. In the United States alone, there were 207,090 new cases of female breast cancer in 2010, accounting for the highest number of new cancer cases at 28%. According to statistics from the American Cancer Society, breast cancer in women was the second leading cause of cancer death with an estimated 39,840 deaths in 2010 (Jemal, Center, & Ward, 2010).
Family history is a well known risk factor for breast cancer, with an estimated 5–10% of cases attributable to inheritance of an autosomal dominant gene (Bradbury & Olopade, 2007). History of breast cancer in a first degree relative is especially significant, with an estimated relative risk of 2–3 times that of the general population. The most risk is for relatives of sick people with premenopausal cancers and bilateral cancers (involving both breasts) , rising up to 9 times compared to the general population. Some genetic mutations have been implicated, among which the most important are BRCA2 and BRCA1 gene mutations accounting for about 20% of familial cases. As for the racial influences, white women are more prone to have breast cancer than black women; however black women are tend to be recorded with higher stage tumors and have less general survival than whites. So, this is in part according to disparities in access to the health care, screening and disparities in treatment (Hayanga & Newman, 2007). Hormones are known risk factors for breast cancer. This can be seen when person considers the large amount of breast cancers which carry receptors for the progesterone and estrogen. Among the risks are nulliparity (never having borne a child), older age at first pregnancy, and early menarche/late menopause. Comparing geographic influences, an increased incidence is seen in the United States and the Western countries when compared to non-Western countries, with the risk for the US/Western group 4–7 times that of the non-Westerners.
Diagnosis and Staging
In the diagnosis course, the average clinical scenario is a woman who finds a lump during the self-examination of her breast. There are multiple types of biopsies and methods of diagnosis used to diagnose the breast cancer, depending on the clinician and institution. TNM cancer staging established by American Joint Committee of Cancer is commonly used staging system and includes four different classifications: pathologic, clinical, autopsy, and recurrence. Clinical classification is founded on evidence which is gathered before treatment of the tumor, and is often used to make regional/local treatment recommendations. It includes physical examination, imaging studies, including mammography and ultrasound, and pathologic examination of the breast or other tissues as appropriate to establish the diagnosis of breast cancer. For clinical staging, this usually takes the form of needle biopsies. Pathologic classification includes the results of clinical staging, as modified by evidence obtained from the surgery and from detailed pathologic examination of the primary tumor, lymph nodes and distant metastases. It is used to assess prognosis and to make recommendations for adjuvant treatment. Classification of a recurrent tumor includes all information available at the time when further treatment is needed for a tumor that has recurred after a disease-free interval. Autopsy classification is used for cancers discovered after the death of a patient, when the cancer was not detected prior to death.
Treatments for the Breast Cancer
The recommended treatments for breast cancer include surgical removal, radiation therapy, chemotherapy and hormonal deprivation for estrogen dependent cancer. Complications are an inevitable part of the medical treatment. Awareness of possible complications should allow all possible measures to minimize their occurrence. Open discussion with patients allows a realistic expectation of outcome and informed consent to treatment. Lymphedema of the breast after conservation therapy is prevalent. The breast is swollen and slightly erythematous with edema. This appearance is not uncommon following treatment of breast cancer by wide excision and radiotherapy, particularly after axillary clearance surgery, and an upper outer quadrant tumor in a large breast. Another problem is the poor cosmetic result following a wide excision of a cancer of the lower inner quadrant of the breast. Hair loss is expected during chemotherapy commonly used for breast cancer.
Breast cancer diagnosis, treatment and surveillance frequently lead to distress. Reactions to the disease can include feelings of vulnerability, sadness, fear, denial and anger. When circumscribed and time-limited, such emotions constitute normal coping mechanisms, allowing individuals to come to terms with the implications of their disease gradually. By convention, comprehensive treatment of depression and anxiety involves a multimodal approach that includes addressing all reversible medical etiologies, individual and group counseling and psychotropic medications. Medical factors exacerbating psychiatric syndromes should, if possible, be minimized or neutralized. Treating clinicians should screen for and address dietary deficiencies such as low vitamin B12 or folate, endocrine dysfunctions such as hypothyroidism, pain syndromes, menopausal symptoms, anemia and substance abuse. Agents with appetite-stimulating properties can be offered to anorectic patients. Nonessential steroid use should be limited as much as is possible. Several clinical trials in breast cancer patients have demonstrated improvements in both quality of life and perception of physical symptoms with both group and individual talk therapies. A variety of models of one-on-one and group talk therapy exist. Brief interventions commonly employed in the cancer setting include the supportive psychotherapy, cognitive behavioral therapy (CBT), and supportive-expressive psychotherapy. Supportive psychotherapists encourage patients to vent their distress within the safety of the therapeutic relationship and aim to bolster patients’ defense mechanisms through the offering of advice, support, and empathy. Because the majority of breast cancer patients rely on polypharmacy, attention to possible pharmacokinetic and pharmacodynamic drug-drug interactions is essential, when considering the addition of a psychotropic medication.
Nursing Care for Breast Cancer
Nursing care affects both short- and long-term surgical outcomes in oncology by playing a critical role in perioperative assessment, teaching, symptom management and posttreatment surveillance. Patients with recurrent or metastatic breast cancer need support and understanding not only from family and friends, but from health professionals as well. They need to be able to talk openly about their cancer, their feeling and concerns, their care preferences, and their decisions about treatment and when to stop treatment. This can be very stressful for some people, and many patients seek support groups of other patients with recurrent cancer.
Nurse-delivered interventions have been instituted to address some of the issues of quality of life for the cancer patients. In one study, cancer outpatients diagnosed with major depressive disorder received a multicomponent intervention delivered by nurses (Sharpe et al., 2004). The intervention was effective, in that 38.5% fewer patients in the treatment group were still depressed at the final 6-month outcome, as compared to patients who received the usual care. In another study, breast cancer patients, who were 3 to 4 months postdiagnosis, received 10 sessions of cognitive-behavioral therapy by telephone (Sandgren & McCaul, 2007). The women, who received the therapy, had less anxiety and confusion at the final 10-month outcome, as compared to the control group.
The role of the Radiation Therapy (RT) nurses is very important, in contrast to their counterpart medical oncology nurses, who have long established roles in the administration of chemotherapy and management of symptoms. With increasingly aggressive cancer treatment regimens being adopted, patients are at risk for multiple toxicities, and the RT nurse must be prepared to assess and intervene as indicated. New and innovative strategies for patient teaching and managing toxicities necessitate a dialogue among all professionals involved in patient care to produce optimal outcomes. RT nurses are primarily responsible for teaching, assessing, and managing toxicities, and supporting patients through a course of irradiation.
Nurses and other health professionals can provide information about resources to help with the concerns shared by the terminally ill patients. They can also help family members understand why discussing these issues doesn’t mean that the patient is "giving up" and may actually be comforting to the patient. For example, some people think calling in hospice means giving up and that it will shorten the client’s survival. However, a recent study of more than 4,000 patients suggests the opposite: the mean survival was twenty-nine days longer for hospice patients than for nonhospice patients (Connor, Pyenson, Fitch, Spence, & Iwasaki, 2007).
Nurses can have important role in promoting early detection and diagnosis of cancer. As respected members of the healthcare profession, they are consulted formally and informally about perceived signs and symptoms of cancer. Through communication, education and intervention, nurses can increase public awareness about cancer. Nurses are well suited to provide the education about prevention measures and general population screening guidelines for early detection and diagnosis of cancer. Relating principles of cancer risk assessment, discussing issues related to genetic testing, educating patients about performing self-examinations, reporting symptoms, and scheduling appropriate screening tests are some examples of their capabilities. Nurses also can facilitate entry into the healthcare system by encouraging appropriate follow-up without delay, providing accurate information on cancer detection and diagnostic procedures, clarifying misconceptions, and referring individuals to trusted healthcare providers or community programs.