Chronic Illness and Long Term Health Problems - Essay Example

Glenn Butcher No. 0474858 Critical Analysis of a Chronic Illness November 21, 2005. Critical Analysis of a Chronic Illness and Long Term Health Problems. Introduction This assignment forms part of the assessment in module 3. The author, a trainee Emergency Care Practitioner (ECP) will analyse the factors surrounding a female patient suffering from a long-term illness. Through researched literature together with evidence-based practice, the author will explore the physiology/pathophysiology of this disease to therapeutic intervention and the impact it has rendered on the patient's psychological and sociological wellbeing in everyday life. The Government's directives and professional body guidelines on treatment of these diseases will be examined with utmost care and support in managing this patient in the community. As stated in Confidentiality NHS Code of Practice on WWW , identification of all the persons and areas involved have been removed to maintain confidentiality. Hence the patient is identified here as patient-X in the assignment. As reported in Cancer Research UK information research centre on WWW, Breast Cancer is the most common cancer for women in UK with over 41000 new cases being reported annually. About 12600 deaths occur annually. Rarely does breast cancer occur in men. As reported graphically in National Statistics on WWW, "Incidence rates increased by 80 per cent between 1971 and 2003, and by 16 per cent in the ten years to 2003." Breast Cancer Incidence rises while deaths continue to fall Age-standardised incidence of and mortality from female breast cancer, England, 1971-2003 (Source: National Statistics) In the same article it is reported that "Earlier detection and improved treatment has meant that survival rates have risen. Five-year survival was 80 per cent for women diagnosed in 1998-2001 in England." According to Cancer Research UK Statistics and prognosis for breast cancer on WWW, "Researchers have recently been working on predicting survival rates so that we have more up to date figures. The first of these predictions were released in October 2005. Overall 10 year survival figures for women diagnosed in the past few years are estimated to be 72 out of every 100 (72%). They also predict that 64 out of every 100 women diagnosed recently with breast cancer (64%) will live for at least 20 years." This appears to be very encouraging; one of such surviving patients is Patient-X. The patient has kindly permitted me to critically analyse this disease. In the year 2000 patient-X was a normal healthy 48-year-old female happily married with two teenage siblings and in full time employment until she noticed a lump in her left breast. She was seen by her local GP who referred her onto a breast-screening unit. Two months later at this appointment patient-X was seen by a specialist who after examining left breast of patient-X requested a mammogram. An X-ray of the breasts was taken and abnormal findings were compared with that of other breast. Results showed that Patient-X had suspected breast cancer and further tests revealed an invasive cancer similar to the one shown below: Fig 1- Showing normal mammary x-ray on the left and right invasive malignancy from mutated cancer cells (Source: Essentials of Human Anatomy & Physiology, Eighth Edition. The reproductive system p545. Pearsons Benjamin Cummings. Publisher- Daryl Fox.). To date patient-X has endured endless treatments together with surgery resulting in removal of the breast and presently suffering from secondary stage bone cancer. Physiology/Pathophysiology Fig 2- Showing normal cell functioning before breast Cancer (Source: breastcancer.org) As reported in Beth Israel Health Care System, Anatomy of Breast on WWW, The mature female breast is composed of essentially four structures: lobules or glands; milk ducts; fat and connective tissue. The lobules group together into larger units called lobes. On average there are 15-20 lobes in each breast arranged roughly in a wheel spoke pattern emanating from the nipple/areolar area. The distribution of the lobes is not even, however. There is a preponderance of glandular tissue in the upper outer portion of the breast. This is responsible for the tenderness in this region that many women experience prior to their menstrual cycle. It is also the site of half of all breast cancers. The lobes empty into the milk ducts which course through the breast towards the nipple/areolar area. There, they converge into 6-10 larger ducts called collecting ducts which enter the base of the nipple and connect with the outside. During lactation (breast feeding), the breast milk follows this course on its way to the feeding infant. According to Oncolink on WWW, When cells in the breast begin to grow out of control and can then invade nearby tissues or spread throughout the body. Large collections of this out of control tissue are called tumours. However, some tumours are not really cancer because they cannot spread or threaten someone's life. These are called benign tumours. The tumours that can spread throughout the body or invade nearby tissues are considered cancer and are called malignant tumours. Theoretically, any of the types of tissue in the breast can form a cancer, but usually it comes from either the ducts or the glands. Because it may take months to years for a tumour to get large enough to feel in the breast, we screen for tumours with mammograms, which can sometimes see disease before we can feel it. As reported by Lippincott Williams & Wilkins in Understanding breast cancer! Anatomy& Pathology. The actual cause of breast cancer is not known however; as there is a higher rate of these cancers in women it is thought that the hormone oestrogen plays a contributing factor in breast cancer. For a woman these risks are thought to be: a family history involving breast cancer, early or late menstruation, never pregnant or first pregnant after the age Breast profile: A ducts B lobules C dilated section of duct to hold milk D nipple E fat F pectoralis major muscle G chest wall/rib cage Enlargement: A normal cells B lobular cancer cells breaking through the basement membrane C basement membrane Figure 3 - Normal breast with invasive lobular carcinoma (ILC) in an enlarged cross-section of the lobule. (Source: breastcancer.org) of 31, history of breast cancer, had endometrial /ovarian cancer or have had exposure to low levels of radiation. It is also thought that our lifestyles attribute towards causative risks in developing this disease such as smoking, diet, household chemicals and stress but, according to Weiss F as reported in Research News on Environmental and Lifestyle Factors there is no evidence to date that proves that these risks have a direct connection in developing breast cancer. Patient-X was a regular smoker before first pregnancy and has a family history in breast cancer, two risk factors thought to be associated with this disease. As reported in DoH on WWW, the then secretary of state for health announced plans to improve and develop UK cancer research by forming a new National Cancer Research Institute (NCRI). This will focus exclusively on cancer research, clinical trials and treatments. The NCRI with consist of the Medical Research Council, cancer research Campaigns, Cancer Institutes and the Pharmaceutical Industry. With a 160 million investment from the government and equal amounts from the other organisations and a further 20 million funding each year from the government, the NCRI through groundbreaking research will improve on screening, drugs and treatments with the result in reducing the mortality rates of this disease. As an ECP I can keep up to date with this research through the web site and the knowledge past on to the patient/relatives and colleagues when needed. As stated by Rosenthal G. in The Genetics of Breast Cancer on WWW, our bodies are made of billions of cells controlled by genetic material. In these cells are DNA strands made up of different genes, the blueprint of our appearance. They come in duplicated pairs, half our hereditary material (genes) come from the maternal side and half from the paternal side of our parents. Gonzalez A. reported in Student BMJ, Beginner's Guide to Genetics: Cancer Genetics on WWW that cells are constantly dividing and their genetic material is in the form of DNA structure, which is always duplicated and passed on to new cells. As there are two identical DNA strands in each cell, when one of the DNA strands becomes damaged the DNA has a repair system that detects errors and by triggering enzymes and proteins encoded by copying the exact genes from the healthy identical DNA strand to restore the damaged genes on the effected strand. This system can also cause cell death known as apoptosis. Certain groups of genes on the strand called oncogenes and tumour suppressor genes are thought to be responsible for cancerous mutation. The oncogenes genes control cell growth; if these genes become abnormal they can inhibit apoptosis, become dominant and allow cells to grow out of control. Only one of the copies of genes is needed for these genes to alter and cause a mutation. See table 1 for examples: Table 1 Representative oncogenes of human tumours Oncogene mechanism Type of cancer Activation abl Chronic myelogenous leukaemia, acute lymphocytic Translocation bcl-2 Follicular B cell lymphoma Translocation erbB-2 Breast and ovarian carcinomas Amplification c-myc Burkitt's lymphoma Translocation PML/RAR Acute promyelocytic leukemia Translocation H-Ras Thyroid carcinoma Point mutation K-Ras Colon, lung, pancreatic and thyroid carcinomas Point mutation Ret Multiple endocrine neoplasia types 2A and 2B Point mutation Ret Thyroid carcinoma DNA rearrangement Table 1 Representative Oncogenes of Human Tumours (Source: Student BMJ, Beginner's Guide to Genetics: Cancer Genetics) As reported by Gonzalez in the same article: These are genes that stimulate cell growth and division or inhibit apoptosis. When present, oncogenes behave as dominant traits, so mutation is needed in only one of the copies of the gene for its function to alter. Wild type oncogenes participate in normal cell function and are known as proto-oncogenes. When a mutation occurs, they transform into oncogenes. This also applies to their products. A proto-oncogene encodes a normal protein, and the product of an oncogene-an oncoprotein--has structural changes because of gene modifications. Table 2: tumour suppressor genes Gene Type of cancer APC Colon or rectum carcinoma BRCA1 Breast and ovarian carcinomas p53* Brain tumours; breast, colon or rectum, oesophageal, liver and lung carcinomas; sarcomas; leukaemias and lymphomas PTEN Brain tumours; melanoma; prostate, endometrial, kidney and lung carcinomas Rb* Retinoblastoma; sarcomas; bladder, breast and lung carcinomas VHL Renal cell carcinoma WT1 Wilms' tumour Table 2: Tumour Suppressor Genes (Source: Student BMJ, Beginner's Guide to Genetics: Cancer Genetics) Tumour suppressor genes are the counterpart to oncogenes they produce a protein that suppresses tumour cells. If only one of the two copies of gene remain active the gene can continue to form proteins to suppress tumour genes but if this functional gene changes by mutation then the gene stops forming these proteins and the cancer tumours continue to progress. For examples of these genes see table 2 above. As reported by Wikipedia encyclopedia on WWW, "Two genes, BRCA1 and BRCA2, have been linked to the rare familial form of breast cancer. Women in families expressing mutations in these genes have a much higher risk of developing breast cancer than women who do not. Together with Li-Fraumeni syndrome (p53* mutations), these genetic aberrations determine around 5% of all breast cancer cases, suggesting that the remainder is sporadic. Genetic counselling and genetic testing should be considered for families who may carry a hereditary form of cancer." In addition as shown in table 1 gene erbB-2 mutation also leads to breast cancer. Since it has already been mentioned that the Patient-X in question has a family history of Breast cancer, I tried to acquire the patient's medical notes, but failed. Hence, I am not able to ascertain the exact gene of the four possible genes responsible for this progressive disease. Treatment Before any treatment can commence pre-treatment evaluation in the form of a biopsy from the effected breast has to be performed. Then clinical staging via a histological examination of the sampled tissue is performed to determine whether the tumour is benign or malignant and to assess the extent of the disease if there are any lymph node involvements. This system is known as Tumour-Nodes-Metastasis system (TNM). Following five stages are generally observed in case of cancer starting from stage 0. Figure 4 - Five different stages of Breast Cancer from Stage 0 to Stage 4 (Source: breastcancer-answers.com) It was observed that Patient-X presented at stage three of this disease, which was a malignant tumour with lymph node involvement. After discussing which treatment was appropriate with the oncologist, removal of the breast known as modified radical mastectomy followed by radiotherapy was favoured as the tumour was larger than two inches with positive lymph nodes involved and tamoxifen prescribed as an after treatment. As reported in Imaginis the breast health source on WWW, A modified radical mastectomy (whole of breast) is only carried out when malignant tumours have spread throughout the breast, Lumpectomy partial removal of the breast is performed if there is only one benign tumour. The radiotherapy is favoured to target cancer cells and any that linger after surgery, each day for five to seven weeks of treatment. This is the normal kind of therapy carried out in UK. As reported by Dr. Weiss M. in Tamoxifen on WWW, tamoxifen is a hormonal therapy and works against hormone receptor positive breast cancers and reduces the risk of reoccurrence and other breast cancers. This can be prescribed for up to five years, taken orally in the form of tablets. Patient-X also committed that one time their oncologist suggested having both breasts removed as a preventative measure. This was declined by patient-X as she was not ready for such aggressive treatment when loosing one breast was bad enough and to loose both when the other breast is normal even worse. Prophylactic mastectomy is performed when there is a genetically abnormal BRCA1 or BRCA2 breast gene in the family. As discussed by Carlo Palmieri and Anjana Singh in Student BMJ- Cancer medicine: principles of treating malignant disease Part one: surgical oncology on WWW, very few breast cancer cells are left behind that could develop into cancer, it is only about ninety percent effective but not guaranteed and these benefits decrease as you get older. This treatment fits in the National Institute for Clinical Excellence (NICE) guidelines on WWW, which states that radiotherapy should be regarded as standard therapy for all women who have undergone breast surgery such as an mastectomy and hormonal therapy for longer term treatment. Patient-X experienced some side effects after this treatment. There was some reddening and swelling over the site of surgery with stiffness and pain when raising her left arm. Cancer backup suggests that this is normal after a mastectomy, the reddening resulting from the radiotherapy is similar to sunburn after three to four weeks of treatment, the amount of reaction depends on the area being treated and the individual's skin. The associated pain under the arm when elevating is from the surgery procedure or their lymph glands may either have been removed during surgery or lost there function due to the radiotherapy causing this discomfort. As reported in Acetaminophen Information from Drugs.com on WWW, the patient-X was administered acetaminophen (Tylenol). This is a pain reliever and an anti pyretic, taken with food or milk to prevent stomach upset. To ease the side effects for the patient, if their current medication is having no effect, as an ECP, I would administer intravenously an anti-emetic such as metoclopramide and morphine sulphate for pain relief or take advice from the oncology ward or rapid response teams if my treatment is not appropriate. Patient-X had monthly checkups for three months with the oncologist followed by yearly checkups at the unit. After a two-year remission period patient-X reported back pain along with leg pains while sleeping, which increased and worsened on moving around. Their GP referred patient-X to the oncologist due to her history of breast cancer. A blood test revealed that patient-X had secondary bone cancer. As reported in cancerhelp.org.uk on WWW, fact sheet on secondary breast cancer suggests that this is not a new cancer, the breast cancer cells spread either via the lymph nodes or through the bloodstream and metastasising onto the bone. Calcium and various proteins make up our bones and when these secondary metastases invade the bone, they alter the bone structure releasing calcium into the bloodstream resulting in high levels of calcium in the blood known as hypocalcaemia. A bone scan of the patient-X confirmed this cancer had spread, see similar picture given in figure 5 below. This scan is more sensitive to an x-ray, a small amount of radioactive substance is injected into the vain, which shows hot spots, a build-up of this substance in the affected area of the bone. After discussing which treatment was appropriate with the oncologist again radiotherapy, chemotherapy and bisphosphonates was agreed. The radiotherapy is focused by targeting the affected sites to shrink the metastases to relive the pain and prevent any pathological fractures. Figure 5 - Cancer spread over to bones resulting into altering the bone shape (Source: breastcancer.org) As stated by Frazier T, Weiss M, Rosenberg A. in Preventive Surgery Options on WWW, chemotherapy is a systemic therapy that affects the whole of the body through the bloodstream, a combination of these drugs known as regimens is administered and works by stopping and killing cells that divide rapidly namely cancer cells that have spread or are still lingering around in the body. Two most common regimens of drugs licensed and approved by NICE used in chemotherapy are Adriamycin - a protein inhibitor of gene replication and toxal a natural agent from the bark of the yew tree interferes with the cell structure and cell division. Fluorouracil (5-FU) is a false building block causing the cancer cell to die and cytoxan (cyclophosphamide) interferes with cell replication. Which of these two regimens patient-X received I am unable to ascertain without having their medical notes. As stated in Breast Cancer Care on WWW, Bisphosphonates is a medication that can be taken orally and acts by reducing the breakdown of the bone therefore reducing the calcium level in the blood and helps reduce pathological fractures, this is not a cancer treatment but maintains a level of calcium in the bone. To date patient-X is still receiving this therapy. The chemo is administered intravenously in cycles to allow a rest period between treatments for the body to recover. There are some noticeable side effects from this treatment; patient-X has experienced fatigue, nausea and hair loss. As reported in Chemotherapy side effects on WWW, chemotherapy targets cancer cells and normal healthy cells such as red blood cell causing low haemoglobin counts resulting in low oxygen levels which in turn cause fatigue, target hair cell and thus loss of hair and cells in small intestinal tract release serotonin which send signals to the vomit area in the brain thus giving vomiting sensation. The patient-X is having regular blood tests for the blood count and a prescription of Zofran an anti-emetic to control nausea and vomiting. If I am called again as an ECP, my treatment would be as before and liaise with any district nurses, Macmillan nurses, home intervention teams and if they are not available speak to the oncology ward with the possibility of referring the patient to them. Under NICE guidelines, oncology wards should be available for patients who may not have adequate support to cope with the adverse side effects of chemotherapy. Another side effect associated with this disease is depression, which leads on to the next section of this essay psychological wellbeing. Psychological/Sociological wellbeing. As stated in Secondary breast cancer on WWW, for many women living with secondary stage of cancer is the toughest part of diagnosis, while some plan on daily basis without having any long term plans, others take it in stride of life. Life partner too experiences the same emotions as that of patient and starts planning for the future if the patient had previously taken care of the whole family and may experiencing more responsibilities. It may be difficult for the patient to express his/her ideas, feelings etc., sexual relationship may probably be affected. The time when patient is already feeling isolated, friends may think not to disturb the patient and of course may not come to the patient's bedside thus increasing their isolation and loneliness. Patients may get help and support from some neighbours, care nurse, specialist, GP or a social worker. Practical help may be easier to find then emotional support, with communication becoming simple - Patient can just give a call to seek support from support groups, telephone of different support groups can be obtained from the breast care nurse. The patient can even talk about the treatment with Macmillan nurse, Breast Cancer Care's helpline etc., Religious belief is very important part of many people's lives and many find that gives them strength and comfort particularly during stressful times. Nobody can ever predict how long a patient can survive with secondary stage breast cancer, infact sometimes it becomes a chronic illness and people gradually learn to live with cancer. While majority fear from death some do not, in the process some think what would happen to the huge assets they had accumulated during their life time and how their future generations make good use of all the assets. Some get along and keep all the documents in order before they reach the ultimate end. Support can be got from district nurse, Macmillan nurse, Marie Curie nurse, Palliative care team/Home Care team, occupation therapist and Social worker. Support Material Guidance on Cancer Services- Improving Outcomes in Breast Cancer, Manual Update issued by NHS, National Institute of Clinical Excellence. Secondary Breast Cancer issued by Breast Cancer Care to help in all aspects such as psychological and sociological issues of the patient. Support Groups In addition following organisation/support groups with their contact addresses are doing a great job to humanity: CancerBACUP 3 Bath Place Rivington Street London EC2A 3JR Office: 020 7696 9003 Freephone helpline: 0808 800 1234 (Mon-Fri, 9am-7pm) Email: info@cancerbacup.org.uk Website: www.cancerbacup.org.uk CancerBACUP is the leading national information and support charity for people affected by cancer. Services include a helpline, staffed by specialist cancer information nurses, a website, cancer information booklets and local information centres. All CancerBACUP services are free to people affected by cancer. Macmillan Cancer Relief 89 Albert Embankment London SE1 7UQ Telephone: 020 7840 7840 Macmillan CancerLine: 0808 808 2020 Textphone: 0808 808 0121 Email: cancerline@macmillan.org.uk Website: www.macmillan.org.uk Macmillan Cancer Relief is helping people who are living with cancer through the provision of immediate practical and emotional support. Specialist services include Macmillan nurses and doctors, cancer centres, a range of cancer information and direct financial help. The Macmillan CancerLine provides information and emotional support. Textphone available. Marie Curie Cancer Care 89 Albert Embankment London SE1 7TP Administration: 020 7599 7777 Email: info@mariecurie.org.uk Website: www.mariecurie.org.uk Marie Curie Cancer Care provides high quality nursing, totally free, to give terminally ill people the choice of dying at home supported by their families. Bristol Cancer Help Centre Grove House Cornwallis Grove Clifton Bristol BS8 4PG Telephone: 0117 980 9500 National helpline: 0845 123 23 10 Email: info@bristolcancerhelp.org Website: www.bristolcancerhelp.org One-day and one-week holistic courses (led by doctors) for cancer patients which include counselling, relaxation, visualisation, meditation, art and music therapy, healing and dietary advice. Also provides seminars and courses for health professionals. Following general organisations are also helping for the cause British Association for Counselling and Psychotherapy (BACP) BACP House 35-37 Albert Street Rugby Warwickshire CV21 2SG Telephone: 0870 443 5252 Minicom: 0870 443 5162 Email: bacp@bacp.co.uk Website: www.counselling.co.uk Aims to promote counselling and psychotherapy and raise standards. Produces a directory of counsellors and psychotherapists, also available online, and will send a list of counsellors and psychotherapists in your area. Hospice Information St Christopher's Hospice 51-59 Lawrie Park Road London SE26 6DZ Telephone: 0870 903 3903 Email: info@hospiceinformation.info Website: www.hospiceinformation.co.uk Provides information on hospices and palliative care services in the UK and abroad. Concluding Remarks In concluding remarks I would like to suggest that as the Adage goes "Prevention is Better Then Cure." Once a man or woman comes across some suspicious lumps in the breast area, immediately the individual can contact a GP, and if required may also under mammography to detect any possibility of carcinogenic tumour. If the test proves positive for cancer then nothing to worry about. Follow the advice of a specialist depending on the stage of breast cancer and discuss without any fear or shyness. Every possible care is to be taken to avoid the spreading of cancer. I as an ECP would certainly suggest people to adopt the procedures (Chemotherapy/ Radiotherapy) and take the drugs as suggested by the doctor. I would encourage them to live for someone who loves them, thus helping them psychologically. Works Cited Department of Health 2003. "NHS Code of Practice Confidentiality." Cancer Research UK, Information research centre. "Breast Cancer Statistics for the UK" Cancer Research UK, "Statistics and prognosis for breast cancer" Essentials of Human Anatomy & Physiology (Eighth Edition). The reproductive system p545. Pearsons Benjamin Cummings. Breast Anatomy - breastcancer.org, Pictures of Breast Anatomy. Oncolink - Abramson Cancer Centre of the University of Pennsylvania Understanding breast cancer! Anatomy& Pathology - Understanding breast cancer! (4th Edition) by Lippincott Williams & Wilkins (2005). Invasive Lobular Carcinoma (ILC). Research News on Environmental and Lifestyle Factors Department of Health 2001 (DoH) Health Secretary announces plans to improve and develop UK cancer research The Genetics of Breast Cancer by Rosenthal G, (2005). Student BMJ, Beginner's Guide to Genetics: Cancer Genetics by Gonzalez A,( 2005) Wikipedia encyclopedia breastcancer-answers.com Imaginis the breast health source, The Breast Health Resource Tamoxifen by Dr. Weiss M. Cancer medicine: principles of treating malignant disease Part on Cancer medicine. studentBMJ by Palmieri C, Singh A.(2001) National Institute for Clinical Excellence (NICE), nice.org - Guidance on Cancer Services. Acetaminophen Information from Drugs.com(2003) cancerhelp.org.uk breastcancer.org - Breast Cancer spread to bones(2005) http://www.breastcancercare.org.uk/Breastcancer/Secondarybreastcancer/Secondarybonecancer Preventive Surgery Options by Frazier T, Weiss M, Rosenberg A Breast Cancer Care http://www.breastcancercare.org.uk/Breastcancer/Secondarybreastcancer/Secondarybonecancer Chemotherapy side effects on Chemotherapy.com (2005)Easing the chemotherapy journey. Secondary breast cancer < http://www.breastcancercare.org.uk/Publications/Factsheets/4942/Secondarybonecancer-Jan05updatedOct05.pdf> Read More