Breast Cancer, Anatomical and Physiological Aspects - Essay Example

?Psychosocial Essay, Breast Cancer-Lab Report Word Count: 3,199 Introduction The descriptive narrative of an interviewed patient, Gillian, a 55years old White, British woman, shows the resolve and courage the lady has after being diagnosed for breast cancer a second time. From her expressed sentiments it is clear that she is more frustrated than depressed, as she shows concern about the functionality of her body rather than despair, which is a natural reaction in most cases. However, this brief narrative might be insufficient for evaluation of her real actual psychological state, as she might be putting up a brave stance in the clinical setting. Gillian is a modern technocrat as evidenced by her professional affiliation to the IT (Information Technology) industry. She has undergone a partial mastectomy (lobectomy) previously in an effort to get rid of the tumour in her left breast, with no need for chemotherapy being felt by the attending surgeon and physicians at that time. Naturally she had returned to her normal life activities thinking she had been cured once and for all. Her attitude towards the initial surgery is positive, as by her own admission. She declares that the minor scar and no indentation were immaterial cosmetically. But the recurrence of the problem, complicated by accompanying lymphoedema, the latter being a consistent but regular phenomenon after her first surgery, has got her in a mood bordering on desperation with chances of easily being susceptible to depression. The fresh diagnosis of DCIS (Ductal carcinoma in situ), with chances of malignancy and accompanying lymphoedema has Gillian worried about the sequel after the now recommended surgical removal of her left breast and the duration of chemotherapy she needs to endure. Chemotherapy for cancer is already associated with physical, cosmetic and other side effects which a person of Gillian’s education, experience and stature will not fail to realize. Gillian has already been treated with Tamoxifen and Arimidex (anastrozole), which are known to cause potent side effects. She is therefore in a despondent state and needs to be handled carefully by healthcare experts from the fields of oncology, surgery and psychotherapy as well. Anatomical and Physiological Aspects The human breasts technically known as mammae are accessory glands more developed in females, in males their presence being just rudimentary (Gray, 1918). The function of these accessory glands is to secrete milk for the infant which it does for approximately a year after birth. However lactation may cease altogether if breast feeding is discontinued by the mother (Blyth et al, 2004). During embryogenesis, mammae develop partly from the mesoderm as well as the ectoderm (Gray, 1918). The blood vessels and the connective tissue develop from the mesoderm while the ectoderm contributes to the cellular elements within. The initial rudimentary manifestation occurs as early as 3 months of age in the female of the human species and the glandular follicles and ducts develop subsequently, especially during hormonal influences at the onset of puberty. Full development of the follicles occurs only after a successful pregnancy during which the hormonal changes occurring inside the female body preparing it for nursing the infant during its first year of life. The anatomical location of the mammae is in the anterior thoracic region with bilateral symmetry, though the left breast is usually larger than the right one. Each mamma extends from the second rib to the sixth rib, from side of the sternum to the midaxillary line (Gray, 1918). Each breast lies within the superficial fascia and its shape and size is dependent upon genetic, racial, dietary factors as well as the age, parity and menopausal status of an individual (Standring, 2008). Its exact location is in the deep pectoral fascia overlying the pectoralis major and the serratus anterior muscles superiorly with the aponeurosis at the external oblique muscle (Standring, 2008). Loose connective tissue lies between the deep fascia and the breast which imparts a high degree of freedom of movement to the breast. The nipple projects towards the anterior of the chest and its size and shape are determined by age and underlying hormonal influences at various stages of life. The area immediately surrounding the nipple is called areola and has a convoluted surface containing numerous sebaceous and sweat glands (Fig. 1). These glands secrete an oily substance which is essential for latching of the neonate during lactation and also serves as a lubricant (Standring, 2008). The areolar region is rich in melanocytes and the latter abound during pregnancy and lactation making the areola appear darker than in a non-lactating female. Fig. 1: Typical Mamma during lactation (Picture Courtesy: Grey’s Anatomy-Online Edition) A typical breast is a lobated structure within which lies a network of glandular tissue made up of branching ducts and terminal secretory lobules interspersed in a stroma of connective tissue. The functional milk secretory component of the breast is the terminal duct lobular unit and notorious for the first occurrence of malignancy in the mammary gland (Standring, 2008). The primary malignant lesion is initiated in the terminal duct lobular unit in females genetically susceptible to breast cancer. Although each terminal duct lobular unit is described as a discrete unit anatomically, the units are intertwined in a complex manner and cannot be visualized as distinct on naked eye observation during breast surgery (Standring, 2008). The connective tissue stroma within which the lobular units exist is dense and contains fibrocollagenous tissue unlike the interlobular connective tissue, the latter being loose in texture, imparting the functionality of rapid expansion of secretory tissue during pregnancy and subsequent lactation (Standring, 2008). Condensations of connective tissue in the form of fibrous sheets extend from the deep fascia emanating from the chest muscles to the dermis and are particularly developed in the upper portion of the breast and cat as suspensory ligaments for holding the mamma in place (Standring, 2008). Variable amounts of adipose tissue or fat is present in the stroma matrix and determines the size of the breast at different ages, and states of lactation or pregnancy (Fig. 2). Fig. 2: Section of a portion of the breast (mamma) (Picture Courtesy: Grey’s Anatomy, Online Edition). Blood supply to the breast is from the axillary artery, internal thoracic artery and a few intercostals arteries, each supplying fresh blood to different regions of the breast (Standring, 2008). Drainage occurs from a circular venous plexus around the areola as well as from the glandular venules into the axillary, internal thoracic and intercostals veins accompanying the corresponding arteries (Standring, 2008). However, individual variations in vascularisation are common in breast. Lymphatic drainage in the breast has vital repercussions on the spread of mammary tumours as their blockade might influence the spread and dissemination of metastatic cells within the breast. Lymphatics in the mamma are derived from the dermal network and spread extensively within the matrix. The lymphatic vessels in the mamma do not contain valves and the flow is therefore unidirectional. Blockage at any level results in reverse flow of the lymphatic fluid and may aggravate or contribute to the spread of tumour cells. Periductal and perilobular network of lymphatic channels within the breast drains the lymphatic fluid primarily to the respective axillary lymph nodes either through the retroareolar lymphatic plexus or in a direct connection (Standring, 2008). Deeper parenchymal areas are drained by the dermal lymphatic channels and the flow is towards the subclavicular lymph nodes, ultimately all lymphatic channels ending up in the drainage of lymph to the left and the right subclavian veins respectively. Drainage towards the internal thoracic group of lymph nodes may carry the lymphatic fluid to the groin area via the epigastric lymphatic routes (Standring, 2008). However, 75% of the lymph drainage from the breast is to the axillary nodes which are 20-40 in number (Standring, 2008). Neuronal supply to the breast is from the anterior and lateral branches of the 4th to 6th intercostals nerves which carry sensory as well as sympathetic efferent nerve fibres. The nipple is particularly sensitive as it is supplied by the anterior portion of the lateral cutaneous branch of the T4 thoracic nerve (Standring, 2008). Sensory endings in the areola are necessary for stimulation of the breast during suckling which occurs under complex neuroendocrine stimulus and control. The normal physiological function of the breast is to secrete milk essential for nurturing an infant during the first year of its life. Milk production commences immediately after the shedding of placenta under the influence of increasing levels of prolactin and diminishing levels of oestrogen and progesterone (O’Connor, 1998). This secretory function is governed by interplay of hypophyseal and ovarian hormones which interact in a complex manner for triggering the synthesis, and then secretion of milk. Adenohypophysis or the anterior pituitary gland is responsible for triggering the secretion of milk in response to the suckling stimulus provided by the infant which sends signals to the brain. The gland secretes a polypeptide hormone, Prolactin, which is released into the circulation in response to the stimulus. The hormone binds with specific receptors within the breast to induce the synthesis and formation of milk (O’Connor, 1998). The secretion of prolactin is under dopaminergic neuronal control and in addition to the stimulatory action on breast cells; the hormone plays an additional role by suppressing ovulation in the ovaries of a lactating mother. Another hormone, oxytocin, secreted by the posterior pituitary gland or neurohypophysis, plays an important role by inducing ‘milk let-down’ or milk ejection from the breast (O’Connor, 1998). Besides these two primary hormones, other hormones such as insulin, cortisol, thyroid, parathyroid and growth hormone also act in a complex dynamic fashion to influence the functioning of the breast (O’Connor, 1998). The interplay of the anatomic peculiarities, hormonal influences, age and pregnancy exert vital influences on the breast as a glandular secretory organ and occurrence of breast cancer is a complex phenomenon which requires thorough understanding of the above facts including modalities available currently to prevent and treat all types of breast cancer. Breast cancers usually arise in epithelia of lobules and ducts in post menopausal women and may be benign or malignant (Standring, 2008). Early detection and treatment is the only method to alleviate the distress and physical problems associated with the malady. Psychosocial Issues Psychosocial issues have attained prime importance in the rehabilitation of women diagnosed with breast cancer. The primary psychosocial issues confronting women diagnosed with breast cancer are fertility, contraception, pregnancy and breastfeeding as established in an Australian study (Connell et al, 2006). Major fear among such women was the sequel of an unplanned pregnancy and the fear of breastfeeding the child if the pregnancy did come to term successfully. Gillian does not belong to this category as she is above 50 years of age and unlikely to get pregnant. However, cancer itself is a dreaded disease in any form and women are primarily affected by this particular type of cancer, triggering efforts by healthcare authorities worldwide to develop strategies’ to allow such patients cope with the inevitability of surgery, and the ensuing mental trauma and difficulties encountered while establishing oneself again in public life. The interviewed patient, Gillian is faced exactly with this type of dilemma at the establishment of a second diagnosis of breast cancer requiring surgery as well as chemotherapy. She had been diligent enough to visit hospitals at frequent intervals to get her health status assessed from time to time and was confident after the initial surgery that she had been permanently cured. But to her dismay, she is faced again with the physical and mental trauma of undergoing the same procedure, with no surety of getting permanently cured. Her immediate anxiety is about the occurrence of concurrent lymphoedema requiring frequent checkups and the physical distress associated with body conformational changes interfering with day to day activities. This is the reason for her to compare herself with a ragdoll with missing parts. Gillian’s dilemma makes her a prime candidate for depression which will require professional assistance from pertinent healthcare experts. She needs a thorough appraisal of her mental attitude and psychological status in order to allow healthcare professionals to assist her in developing coping strategies according to her present condition. This is necessary for her to develop strategies to re-establish herself in life. The widespread incidence and diagnosis of breast cancer in British women in the last few decades has already stimulated intensive research on the psychosocial issues (Poole, 1997). The major psychological stress, particularly among those diagnosed for the first time is the fear of losing self esteem due to the significance of the organ’s association with femininity, motherhood and sexuality (Poole, 1997). The ensuing medical interventions further threaten the family life as well as vocational functioning after the treatment (Poole, 1997). According to the author’s study, major stress is experienced during the waiting period i.e. at the pre-biopsy stage, when the patient is anxious regarding the invasiveness of the procedure, fear of a positive diagnosis, the complexities associated with treatment, as well as the family, social and community implications of a positive diagnosis, the latter disrupting relationships, particularly with one’s spouse. This necessitates the identification and implementation of appropriate psychometric instruments to evaluate stress prospectively, in a stage specific manner, according to the author (Poole, 1997). Research studies conducted in the past have revealed that young women with breast cancer usually experience changes in quality of life, psychosocial adjustment, and adaptation to survivorship issues while undergoing radiation therapy (Dow & Lafferty, 2000). The study revealed that younger women were more prone to psychosocial distress than their older counterparts. At the same time the study also revealed that Caucasian women diagnosed at an early age are less likely to suffer extreme sequels like mortality as compared to African-American women (Dow & Lafferty, 2000). Women who are diagnosed and treated at a younger age are more prone to risk of recurrence in later life, requiring efforts by healthcare professionals to provide them with psychosocial support. Psychosocial rehabilitation efforts should therefore concentrate on evaluating each case according to the age and peculiar circumstances of the patient. An important facet related to the positive diagnosis of breast cancer is the inherent fear of sexual dysfunction associated with the disease (Shell, 2002). As proper sexual functioning is an important aspect of daily life, it has vital implications on the psychological status of a patient diagnosed with breast cancer requiring expert counselling. Sexual dysfunction can not only affect the sufferer but the family as well, particularly the spouse, with far reaching implications on personal and family life. An added complication has been the current availability of molecular diagnostic techniques, which allow the evaluation of genetic susceptibility and predisposition for breast cancer at an early stage (Pasacreta, 2003). Demonstration of BRCA ? genes has been identified as an indicative test for predisposition to develop cancers of different kind later in life, including breast cancer (Pasacreat, 2003). The availability of such tests and the establishment of a positive result for predisposition to breast cancer can put undue psychological stress on the person who undergoes such an examination, even if they don’t get the disease at any stage of their life. Ethical implications of such genetic testing therefore need careful perusal by healthcare authorities in countries where such tests are available. They need to decide whether the results of such tests should be revealed to the patient, or whether the test itself needs to be conducted at all. Lymphoedema is a cancer treatment related adverse effect of the ipsilateral arm or hand which is greatly feared and less understood by the affected persons (Paskett, 2008). Lymph systems usually get disturbed immediately after drastic surgery such as breast cancer in which the whole breast is removed. Backup of lymphatic fluid in the interstitial area causes swelling, pain and rarely loss of sensation (Paskett, 2008). Risk factors for development of lymphoedema include obesity, cellulitis, infection, fully axillary node dissection, radiation and chemotherapy. Gillian has been exposed to treatment by Tamoxifen and Arimidex previously which exposed her to side effects such as sudden numbness or weakness, headache, pain or swelling of one or both legs, swelling of hands and feet, etc., and in addition she had lobectomy performed on her in which some lymphatic tissue loss must have occurred. She is therefore a likely candidate for development of lymphoedema. Low body mass index ( Read More

 

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