Published: Thursday, May 03, 2007

1. Options for treatment of breast cancer
2. Patient needs during the treatment decision-making phase
3. How nurses can help during the treatment decision-making phase

1. Options for treatment of breast cancer

The treatment of breast cancer includes the treatment of local disease with surgery, radiation therapy (RT), or both, and the treatment of systemic disease with chemotherapy, hormonal therapy, biological therapy or combinations of these. The need for, and selection of, various local or systemic therapies are based on the various prognostic and predictive factors. Patient preference is also a major component of the decision-making process, especially in situations in which survival rates are equivalent among the available treatment options.¹

The treatment recommendations described in this section are based on the Canadian Clinical Practice Guidelines for the Care and Treatment of Breast Cancer, the National Comprehensive Cancer Network’s Clinical Practice Guidelines in Oncology (Breast Cancer), or recommendations from the BC Cancer Agency’s Provincial Breast Tumour Group.

2. Patient needs during the treatment decision-making phase

Immediately after diagnosis, patients are required to make crucial treatment decisions which may include what type of surgery, adjuvant systemic therapy, and radiation therapy to have. They may even need to decide who their surgeon or oncologist will be and even where to have treatments. Patients require information and support to help make these difficult decisions about the risks and benefits of these treatments and how they will impact their prognosis.

Distress with treatment decision-making that will impact prognosis is interwoven with distress over treatment decisions that may impede quality of life, and the need to adjust to such physical and emotional changes. Type of surgery, choice of chemotherapy when more than one choice is acceptable, type of radiation therapy (external beam, brachytherapy), and the decisions regarding hormonal suppression options are some of the issues that have emotional consequences because they affect the physical body, anxiety, mood, and stamina.² Once the treatment plan is decided, women with breast cancer may experience some relief of anxiety and distress, but new fears may arise in anticipating and receiving treatment.³

A patient’s psychological well-being and recovery from surgery is enhanced when she is prepared for what to expect pre and post-operatively so she can plan for home supports, time off work and child care. Concerns about body image, mobility, pain and lymphedema are common. "Some women electing breast conservation will experience lingering doubts about the comparable efficacy of this treatment approach to mastectomy, and they may need continued support and reassurance about their treatment choice."⁴

Preparation for radiation therapy can help alleviate anxiety associated with being alone in the treatment room while the therapy is delivered, baring their breasts and disrobing among technical staff, and dealing with potential skin reactions, local symptoms, and fatigue. Health care providers can help by providing thorough explanations on what to expect, by attending to side effects when they arise, and by providing "reassurance about their normalcy and the expected eventual recovery and successful results."⁴ The waiting room of the radiation therapy department is sometimes distressing to breast cancer patients, especially when they see patients who are much sicker and are receiving palliative therapy for advanced cancer. Nursing and physician staff should acknowledge these issues and directly address them when breast cancer patients report their concerns about their own health and mortality.⁴

Decision-making regarding adjuvant systemic therapies can be very stressful. There is a wide range of adjuvant therapies available to women with breast cancer and several options may be offered. Adding to this already challenging situation, patients compare notes with other patients and hear media reports about the latest results of clinical trials presented at scientific meetings. This leads patients to wonder if they are being recommended the latest and best treatments. Some may wish to enter clinical trials or elect for less established therapies over standard approaches. The process of gathering information is often stressful, but usually leads to a better understanding and acceptance of the treatment plan.⁴

The thought of chemotherapy creates fear in the majority of people and may affect their decision to accept this treatment. Hair loss, nausea, and vomiting are among the most distressing side effects, followed by fatigue and changes in body image and weight.⁵ However, "most adjuvant chemotherapy is well tolerated, and women often continue many of their usual activities (childcare, household activities, paid employment) albeit often on a reduced schedule, especially modified by treatment administration.⁵

Although there is good medical evidence for the benefits of tamoxifen therapy in improving survival and preventing breast cancer recurrence, many women have concerns about the risk of developing endometrial cancer and blood clot. Tamoxifen's potential effects on quality of life (psychological well-being, weight gain, hot flashes, and sexual functioning) are also reported, although many of these problems are common in breast cancer survivors and are not specifically related to tamoxifen.⁵ With the more frequent use of aromatase inhibitors in the adjuvant setting, women may wish to have this more recent information and to discuss its implications.⁵

Lastly, "over 70 percent of women become amenorrheic following breast cancer treatment. For younger women who develop breast cancer, amenorrhea is accompanied by a host of hormonal changes either coming on prematurely or intensifying menopausal symptoms in older women.⁵ Managing menopausal symptoms in women with breast cancer is challenging because hormone replacement therapy is not recommended in this patient population. Menopausal symptoms can affect mood, cognition, energy, weight, sexual functioning, and fertility. Women need to weigh out the benefits of treatment recommendations in terms of survival and recurrence rates with potential side effects that can significantly affect quality of life.

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3. How nurses can help during the treatment decision-making phase

In general, nurses can assist patients during the treatment decision-making phase by assessing their existing knowledge regarding treatment options, supplementing and reinforcing information provided by the surgeon or oncologist, and advising patients when they need to seek more information or clarification from their physicians. Specifically, nurses can use the following suggestions to help their patients make treatment decisions that are right for them.

• Clarifying physician recommended treatment plans, ensuring that they are clear on the risks and benefits in terms of survival and recurrence rates
• Reassure women about the varied prognoses of women with breast cancer and that many different treatment strategies can be used for the same stage of disease
• When several treatment choices are offered, assist patients to explore these options in terms of consistency with good practice to fit their needs, values, beliefs and lifestyle
• When available, use existing decision-making tools to assist patients in making treatment decisions
• Encourage patients to refer to appropriate sections of the "Breast Cancer Information Kit" for more information about treatments and management of side effects
• In advance of surgery, use verbal and written means to reinforce instructions on pre-operative and post-operative care, including instructions on caring for incisions, drains, and arm exercises
• Reinforce information on potential side effects of each treatment option, the percentage of people who experience them, and how these side effects can be managed
• Ensure that patients have received appropriate written information on each recommended adjuvant treatment option offered, ensuring that absolute gains to the patient are explained (survival and recurrence rates)
• Provide written information on potential side effects of each adjuvant treatment, the percentage of people who experience them, and ways they can be managed
• Explain how treatments are delivered and the time frames for each (chemo, radiation etc.)
• Reinforce information on safe, acceptable time frames for treatments to begin
• Encourage exercise and healthy nutrition
• Encourage relaxation activities to help alleviate stress
• At each appointment, assess the patient's level of distress in each of these areas and address issues through appropriate referrals or by addressing symptoms. Remember that not all symptoms are directly related to the treatments themselves:⁶
  • Practical Problems: child care, housing, transportation, work/ school, financial
  • Family Problems: dealing with children, dealing with partner
  • Emotional Problems: depression, fears, nervousness, sadness, worry
  • Spiritual/ Religious Concerns: loss of faith, relating to God
  • Physical Problems: appearance, bathing/ dressing, breathing, changes in urination, constipation, diarrhea, eating, fatigue, feeling swollen, fevers, getting around, indigestion, mouth sores, nausea, nose dry/ congested, pain, sexual, skin dry/ itchy, sleep, tingling in hands/feet

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References:

1. Breast cancer: Practice Guidelines in Oncology, Version 2.2006, 12-05-05 © 2005, National Comprehensive Cancer Network, Inc.

2. Hewitt M, Herdman, R, Holland, J, editors. Meeting psychosocial needs of women with breast cancer. Washington, D.C.: The National Academies Press; National Cancer Policy Board; 2004; pg. 27.

3. Hewitt M, Herdman, R, Holland, J, editors. Meeting psychosocial needs of women with breast cancer. Washington, D.C.: The National Academies Press; National Cancer Policy Board; 2004; pg. 24.

4. Hewitt M, Herdman, R, Holland, J, editors. Meeting psychosocial needs of women with breast cancer. Washington, D.C.: The National Academies Press; National Cancer Policy Board; 2004; pg. 25.

5. Hewitt M, Herdman, R, Holland, J, editors. Meeting psychosocial needs of women with breast cancer. Washington, D.C.: The National Academies Press; National Cancer Policy Board; 2004; pg. 26.

6. Distress Management: Practice Guidelines in Oncology Version 1.2007, 08-10-06 © 2006 National Comprehensive Cancer Network, Inc.

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