BREAST CANCER
Cancer of the breast is the most common malignant condition among women and carries with it the highest fatality rate of all cancers affecting this sex. Breast cancer is rare in men, but when it does occur, it is usually not recognized, until late, and thus the results of treatment are poor.
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).
While history, physical examination, and mammography or thermography may strongly suggest breast cancer, the diagnosis can be made only by microscopic examination of tissue removed by open or aspiration biopsy.
Human 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 breast cancer originated was more central in the older patient population we studied. Breast tissue involutes first in the lobular parts and then in the larger central ductal structures. Declining ovarian function in the premenopause leads to regression of epithelial structures and stroma. The central duct system remains but the lobules shrink and collapse. The last structures to appear with sexual maturity are the first ones to regress. This is reflected in the location of breast cancers in younger as opposed to older women. The cancers originate first in lobular ducts and later in the larger ductal structures (1999).
Breast cancer, unlike colon cancer, probably originates in an involuting target organ with a time relationship between the histogenesis, histoapoptosis, and development of breast cancer. It is surprising that breast cancer does not originate in the developing organ, as is the case for nearly all other epithelial and stromal cancers, which usually initiate and grow in regenerating or rapidly developing tissues. It is rare for breast cancer to develop before the age of 24. This is exactly the time when normal involution starts in most women. Involution of human breast tissue is well known to clinicians through mammography or magnetic resonance imaging and is a normal aging process. The development of breast cancer in involuting tissue argues that susceptibility to breast cancer is probably created much earlier in life (1999).
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). The sense organs for pain are the naked nerve endings found in almost every tissue of the body. Pain has been classified into two major types: fast pain and slow pain. Fast pain is felt within about 0.1 second after a pain stimulus is applied, whereas slow pain begins only after 1 second or more and then increases slowly over many seconds and sometimes even minutes (2000).
Fast pain is also described in many alternative names, such as sharp pain, pricking pain, electric pain and acute pain. Acute pain is generally the result of a specific injury and can be clearly explained in terms of where we feel it in the body. This type of pain is felt when a needle is stuck into the skin, when the skin is cut with a knife, or when the skin is acutely burned. It is also felt when the pain is subjected to electric shock. Fast, sharp pain is not felt in most deeper tissues of the body.
Slow pain also goes by multiple additional names, such as slow burning pain, aching pain, throbbing pain, nauseous pain, and chronic pain. This type of pain is usually associated with tissue destruction. It can lead to prolonged, unbearable suffering. It can occur both in skin and in almost any deep tissue or organ. Chronic pain is the other type of pain which is so called because it can continue for months or years and even trigger additional health problems such as depression and lead to lifestyle changes in attempts to remedy the situation. Breast cancer presents a type of slow or chronic pain. This pain largely results from overstimulation of nerve endings. The nerve endings may be stimulated by inflammatory substances that are produced by damaged cells from the cancer and released from the surrounding capillary network.
Even though all pain receptors are free nerve endings, these endings use two separate pathways for transmitting pain signals into the central nervous system. The two pathways mainly correspond to the two types of pain, a fast-sharp pain pathway and a slow-chronic pain pathway (2000).
The slow-chronic type of pain is mostly elicited by chemical types of pain stimuli but also at times by persisting mechanical or thermal stimuli (2000). Pain impulses are transmitted to the central nervous system by two fiber systems. The nociceptor system responsible for the pain felt in osteoarthritis consists of unmyelinated (2001) C fibers 0.4-1.2 µm in diameter. This slow-chronic pain is transmitted in the peripheral nerves to the spinal cord by the type C fibers at velocities between 0.5 and 2 m/sec. These roots are found in the lateral division of the dorsal roots and are often called dorsal root C fibers (2001). A separate peripheral pain type A delta fiber also carries the fast-sharp pain stimuli.
Because of this dual system of pain innervation, a sudden painful stimulus often gives a double pain sensation: a fast-sharp pain that is transmitted to the brain by the A fiber pathway followed a second or so later by a slow pain that is transmitted by the C fiber pathway.
According to the gate control theory, peripheral nerve fibers carrying pain to the spinal cord can have their input modified at the spinal cord level before transmission to the brain. Synapses in the dorsal horns act as gates that close to keep impulses from reaching the brain or open to permit impulses to ascend to the brain. Small diameter nerve fibers carry pain stimuli through a gate, but large diameter nerve fibers going through the same gate can inhibit the transmission of those pain impulses – that is, close the gate (2001).
The evidence that endogenous sex hormones influence risk of breast cancer has been reviewed extensively elsewhere; for pubertal girls, however, the modulation of endogenous estrogens is much more important. The main difference between high and low risk women for breast cancer is the persistent difference in serum estrogens secondary to early and late menarche. In addition, the serum levels might be further modulated to a great extent by nutrition, body fat, and exercise during puberty. Adipose tissue converts androgens to estrogen by aromatization. Bodies weight (fatness) influences additionally the direction to potent and less potent forms of estrogens (catecholestrogens). Late pubertal development and late menstrual patterns are thought to result in part to smaller amounts of body fat (1999).
Breast Cancer Campaign funds independent research into breast cancer at centers of excellence throughout the UK. The Charity aims to find a cure for breast cancer by funding research which looks at improving diagnosis of breast cancer, better understanding how it develops and ultimately either curing the disease or preventing it.
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.
It is important that healthcare professionals, especially the nurses, examine the breasts of male and female clients. A small amount of glandular tissue, a potential site for the growth of cancer cells, is located in the male breast. In contrast, the majority of the female breast is glandular tissue.
Early detection is the key cure to breast cancer. It is therefore a major responsibility for nurses to teach clients health behavior such as breast self examination. Studies suggest that only a minority of women perform breast self-exams ( 2004).
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.
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).
In all these, the nurses are responsible for co-ordinating care following any operations and/or treatment for breast cancer. As well as supporting the patients and his/her family through the operation and treatment, the nurses can provide the patient and his/her caregivers with clear written and verbal information; and can also examine the patient and arrange any tests that might be needed.
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 contains a wide range of targets and commitments. 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 ( 2005).
The progress report also mentioned that cancer networks have helped improve cancer services and have achieved some particular successes. These include planning for the introduction of new cancer drugs and developing plans for funding specialist palliative care. 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).
There have been many largely anecdotal descriptions of the extreme psychological distress, social, and sexual difficulties associated with breast cancer treatment (1991). Numerous descriptions in the scientific literature and lurid accounts in the popular press continue to chart the psychosocial havoc wreaked by the diagnosis of breast cancer and its treatment, especially if that treatment involves breast amputation.
It is also important to remember that denial is a common and important coping strategy for many women with breast cancer. This is just a normal psychological process and what the nurse can do is to provide support.
For a woman who has already undergone many emotional and physical assaults, the news that she must now go through several courses of chemotherapy or other therapeutic procedures over a period of several months after being diagnosed of cancer is often regarded with a mixture of fear and suspicion. Just as the diagnosis of breast cancer has created denial and anxieties, the need for chemotherapy or other therapeutic procedure may create similar anxieties.
Women with breast cancer also has counselling needs which has to be taken cared of. The primary aim in counseling patients with breast cancer is to help women find their own means of coping with the emotional stresses of having a life-threatening illness. Coping is referred to as ‘constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person’ (1991). The outcome of good coping in this sense means successfully adapting to the difficult and changing physical and emotional demands placed on a woman with breast cancer.
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