BREAST CANCER MANAGEMENT
Breast cancer is the second most common cancer in the world and the most common cancer in women, accounting for 18% of all female malignancies ( 2003). Breast cancer appears to have reached epidemic levels. Talk to any group of people anywhere in the UK and they all seem to have some experience of it–someone in their family, a friend, a neighbor or work colleague. And it is not just a vague impression that this is the case, there are hard statistics to back it up. Every year around 39 000 women and between 200 and 300 men are diagnosed with breast cancer in the UK. Government figures show that the number of people who develop breast cancer every year has increased by 70 per cent since 1971, and by 15 per cent in the ten years to 2000. It is by far the most common form of cancer in women and the most common cause of cancer death in women ( 2004).
SOCIAL LIFE
Although one in eight women will eventually develop breast cancer, it is important to note that this is a cumulative lifetime risk that increases with age. More than three fourths of breast cancer cases occur in women 50 years or older; more than half in women older than the age 65. For women between the ages of 35 and 55 without major risk factors, the chance of developing breast cancer is approximately 2.5% ( 2003). Breast cancer risk factors include family history, menstrual history, pregnancy and breast conditions and diseases.
Breast cancer appears long after the organ finishes its development. Age is associated with the location of the tumors. The area of the breast where the cancer originated was more central in the older patient population studied (1999). Researchers believe the increasing mortality rates in this group reflect changes in various risk factors, such as delayed childbearing, that occurred early in the century ( 1997).
Asian women have traditionally had low breast cancer rates. But at present, invasive breast cancer cases have grown significantly among Japanese and Chinese women, and especially among South Asians and Koreans. Researchers suspect that Asians’ breast cancer rates have risen as immigrant women have adopted elements of a Western lifestyle, especially having fewer children and delaying having children until later in life ( 2004).
PSYCHOLOGY
The presence of cancer in a family produces not only physical but also mental and social problems, which are impossible for the family to cope with alone. There is a demand on the part of the nurse for sympathetic understanding and support in building and maintaining morale of the patient and his or her family.
Friends and relatives can be a major source of support, but face their own difficulties. They have to provide emotional support, physical care and help in making decisions about treatment. Many of the observations about the impact of cancer are as true for them as for the patient. Their response to the illness depends on things such as their relationship to the patient, the stage of the disease and their own personalities (2004).
PAIN MANAGEMENT
Cancer of the breast is generally not painful, though a vague discomfort may sometimes be present. Many, if not most, ailments of the body cause pain and this includes breast cancer. Cancer pain syndromes can result from the progression of the disease or from efforts to cure or control the disease ( 2004).
When talking of cancer pain management, what usually comes to mind are morphine, codeine, music therapy, prayer, and even radiation therapy. At an ever-increasing rate, cancer patients are meeting their pain management needs by using these and other noninvasive procedures. Some of these therapies have very sound science behind them while others rely on the patient’s belief system to offer noticeable effects. However, all of these pain remedies have been shown to help some people dispel cancer pain and achieve a more desirable quality of life ( 2002).
DIAGNOSIS
Tremendous emotional upheaval is common after being diagnosed with cancer. Many cancer patients experience feelings disbelief, shock, fear, and anger. They may also feel overwhelmed by the girth of information about their cancer and their treatment options, by the decisions they are required to make, and by the sudden changes in their lives. It takes time to accept and understand the diagnosis. As overwhelming and painful as a diagnosis of cancer is initially, many cancer survivors say that their struggle against cancer gave them an opportunity to re-evaluate their lives and to find strengths and abilities that they hadn’t known they possessed (2004).
TREATMENT
Surgery, radiotherapy, and chemotherapeutic agents are the major modalities used to treat patients with cancer, though various biologic therapies are beginning to have a significant impact. The basic problem is to make available drugs (natural products or synthetics) that kill cancer cells effectively but are not excessively toxic to normal cells. The table below lists seven major classes of compounds that have been widely used in the treatment of cancer:
Class of Compound
Example
Site of Action
Treatment Use
Alkylating agents
Melphalan
Alkalytes DNA and other molecules
Myeloma
Antimetabolites
Purine antagonists
Pyrimidine antagonists
Folate antagonists
Mercaptopurine
Fluorouracil
Methotrexate
Converted to a “fraudulent” nucleotide and inhibits purine synthesis
Converted to a “fraudulent” nucleotide and inhibits thymidylate synthetase
Inhibits dihydrofolate reductase
Acute myelocytic leukemia
Colorectal cancer
Choriocarcinoma
Antitumor antibiotics
Doxorubicin
Intercalates in DNA and stabilizes the DNA-topoisomerase II complex
Hodgkin’s disease
Other agents
Cisplatin
Hydroxyurea
Causes strand breakage in DNA
Inhibits ribonucleotide reductase
Carcinoma of the lung
Chronic myelocytic leukemia
Plant compounds
Vinblastine
Binds tubulin and inhibits microtubule formation
Kaposi’s sarcoma
Sex hormones
Estrogens
Block effects of androgens in prostatic tumors
Cancer of the prostate
Corticosteroids
Prednisone
Inhibits proliferation of lymphocytes
Myeloma
Insofar as unrestrained cell division is a feature that typifies many malignant tumors, many of these agents are used because they inhibit DNA synthesis. For this reason, they are also likely to damage normal tissues whose cells divide continuously – e.g. bone marrow ( 2000).
Current cancer treatments – “cut, burn, poison” – are recognized as crude and painful. Promising new methods focus on delivering anticancer drugs precisely to the cancer (via monoclonal antibodies that respond to one type of protein on a cancer cell) and on increasing the immune system’s ability to fend off cancer (2004).
PROGNOSIS
The prognosis for women with a type of breast cancer is very good. When treated early (stages 0 or I), 10-year survival rates are reported to be more than 96%. Recurrence of the disease tends to be greater in women whose tumors are of high nuclear grade and show evidence of comedo architectural pattern, making it particularly imperative that women diagnosed with ductal breast cancer in this stage receive close clinical follow-up with routine mammography ( 2001).
PREVENTION
Cancer prevention is defined as the reduction of cancer mortality by reducing the incidence of cancer. This can be accomplished by avoiding a carcinogen or altering its metabolism; pursuing lifestyle or dietary practices that modify cancer-causing factors or genetic predispositions; and/or medical intervention to successfully treat precancerous lesions. Preventive health care is more dynamic than health maintenance because it requires the individual to enhance his or her health status actively, rather than maintain the status quo. The three levels of prevention are primary, secondary, and tertiary (2001).
Primary prevention consists of health promotion activities that are focused on protecting against the occurrence of cancer. It includes teaching patients about healthy lifestyle behaviors. The most consistent finding, over decades of research, is the strong association between cigarette smoking and cancers of many kinds. Not smoking, or giving up, is the single most effective strategy to prevent cancer (2004).
Other examples of modifiable cancer risk factors that are open to primary prevention include alcohol consumption, physical inactivity, and being overweight. Based on current evidence, it is now thought that avoiding excessive alcohol consumption, being physically active, and maintaining recommended body weight may all contribute to reductions in risk of certain cancers; however, compared with tobacco exposure, the strength of the effect is modest or small, and therefore the strength of evidence is often weaker (1998).
Other lifestyle and environmental factors known to affect cancer risk include certain sexual and reproductive practices, the use of exogenous estrogens, exposure to ionizing radiation and ultraviolet radiation, certain occupational and chemical exposures, and infectious agents ( 2004).
Secondary prevention refers to health behaviors that promote early detection, early treatment, and limited disability. For example, genetic testing for high-risk individuals, with enhanced surveillance or prophylactic surgery for those who test positive, is already available for certain types of cancer, including breast cancers. Cervical cytology testing (using the Pap test) leads to the identification and excision of precancerous lesions. Over time, such testing has been followed by a dramatic reduction of cervical cancer incidence and mortality ( 2001).
Tertiary prevention is directed toward rehabilitation after a disease or condition already exists to minimize disability and help the person to live productively with limitations. Tertiary prevention is used when disability is permanent and irreversible. This type of prevention is aimed at minimizing disease progression effects and disability.
EDUCATION
In the absence of screening programs as in the case of poorer countries, primary prevention should take place through health education. By informing women on the early warning signs of reproductive cancers and encouraging them to seek medical examinations and treatment, women would not have to die needlessly.
The NHS Cancer Plan, published in September 2000, sets out the first ever comprehensive strategy to tackle the disease. It is the first time any government has drawn up a major program of action linking prevention, diagnosis, treatment, care and research. The NHS Cancer Plan Progress Report released in March 2005 substantial progress has been made in meeting the Plan’s targets. The thirty-four cancer networks which have been established have achieved important improvements in delivering cancer services across England. These are mostly for educating people about breast cancer how they can possibly avoid it. In addition to the NHS Cancer Plan, the Department has launched other initiatives to improve cancer services, including a tobacco advertising ban and a strengthening of the partnership between the NHS and the voluntary sector (2005).
ASSESSMENT
The assessment and evaluation of every woman presenting for a breast cancer screening program must begin with a complete patient history. Personal and family history is important in assessing each patient’s “risk profile.” Patients should be questioned about personal and family medical history in addition to undergoing a physical exam. Evaluating each patient’s individual risk factors is important, because breast cancer isn’t triggered by a specific virus or by a cause-and-effect association like smoking and lung cancer. Instead, breast cancer seems to develop when a combination of many different events creates circumstances that cause or encourage cancer tumors to grow (1997).
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