Mastectomy for Ductal Carcinoma in Situ, Impact on Patient - Essay Example

? Mastectomy for Ductal Carcinoma in Situ, Impact on Patient Introduction Diagnostic breast biopsy that confirms Ductal Carcinoma in Situ or DCIS diagnosis introduced two techniques of wire-location open surgery and directional vacuum-assisted biopsy with the goals to prevent local recurrence after completion of first treatment, and prevention of invasive breast cancer (Medifocus, 2011). These spell out an end-goal for quality of life for DCIS patient. Education, better access and more widespread availability of screening mammography has resulted in an increase in breast cancer diagnoses (Welch Weloshin & Schwartz 2008). Even though some experts do not consider Ductal Carcinoma in Situ (DCIS) to be an actual cancer, it is the most commonly diagnosed type of noninvasive breast cancer or pre-cancer in women today. In fact, DCIS accounts for approximately 20% of all new breast cancer and precancerous condition diagnoses (Clause Stowe & Carter 2001). With or without treatment, DCIS patients have a very high survival rate; and, for most women diagnosed with DCIS, it is not considered to be a life-threatening condition. Mastectomy is the preferred, and most effective, treatment option for DCIS patients (Katz et al. 2010). However, there is currently very little research regarding how patients are actually affected by choosing mastectomy to treat DCIS; and, since the number of new DCIS diagnoses is continuing to increase, much more research is needed. DCIS, also called intraductal carcinoma, is a condition whereby the cancer cells develop in the milk ducts of the breast and have not moved out of the duct into any of the surrounding tissue (National Institute of Health 2009). As mentioned above, there is disagreement as to whether or not DCIS should be called cancer; and, some experts often refer to it as "stage zero breast cancer" ( Harris & Morrow 2009). Even though DCIS itself is not considered to be harmful, it is a known risk factor for invasive breast cancer (Zuckerman 2009). While most DCIS patients do not develop invasive breast cancer, approximately two percent (2%) of DCIS cases show evidence of metastases and an even smaller percentage of cases do actually develop into invasive breast cancer (Cornfield et al. 2004). Certain biomarkers may help to identify whether DCIS patients are at high or low risk of developing invasive breast cancer; however, more research is necessary to make more accurate risk predictions (Welch et al. 2008). Currently, however, there is no way to determine or predict which DCIS cases will in fact develop into invasive breast cancer. This paper will try to determine the available information on the rationale for selecting this modality; explore literature regarding the physiological/biological basis of the treatment or how the treatment manages the disease, critic the impact this treatment had on the individual and the nurses’ role in addressing this, and consider how the patients’ experience could have been improved. Discussion Overview: Even without treatment, most women diagnosed with DCIS do not go on to develop invasive breast cancer. DCIS patients that do opt for treatment have surgical options, the most common being lumpectomy (with or without radiation therapy) and mastectomy. Lumpectomy followed by radiation therapy and mastectomy have the same high survival rate of 96% and above; however, mastectomy does have a slightly lower recurrence rate than lumpectomy with radiation which has a lower recurrence rate than lumpectomy alone (Holmberg et al. 2008; Hughes et al. 2009). Other factors have been found to affect DCIS recurrence rates (e.g. race/ethnicity) (Tan et al. 2007). For example, black women are at higher risk than white women for the recurrence of DCIS and invasive breast cancer (Id.). Other factors have been found to lead to higher rates of DCIS recurrence, such as extensive DCIS of high grade and large size (Holmberg et al. 2008). Race has also been found to affect DCIS recurrence rates although more research is needed to understand the relationship between race and recurrence of DCIS (Holmberg et al. 2008). Existing research indicates that white women have a lower risk of DCIS, or any other breast cancer, recurring than black women. Mastectomy is becoming the treatment option chosen most often by DCIS patients; however, deciding which treatment to use is a decision that must be made on a case by case basis (Alderman et al. 2008). In certain circumstances, mastectomy is always the preferred treatment, such as when DCIS is present in two or more areas; with large or high grade DCIS; if attempted lumpectomy does not achieve adequate margins; if the breast has previously undergone radiation therapy; if the patient has a connective tissue disease which may complicate radiation therapy; radiation therapy is not convenient or accessible; and, in DCIS patients under 40-years old (Kerlikowske et al. 2009). Since the number of new DCIS diagnoses continues to rise with the increase in the use of screening mammography, much more research is essential in order to understand how patients are affected by the diagnosis and treatment of DCIS (Ernster et al. 2002). A good deal of research exists which explores the quality of life that patients may experience after treatment for invasive breast cancers (Virnig et al. 2010). However, only a handful of research has been conducted in order to determine QOL in DCIS patients after mastectomy; and, much more research is necessary, especially when considering that DCIS accounts for approximately 20% of all new breast cancer diagnoses (Claus et al. 2006). Claus et al. (2006) found differences were insignificant regarding QOL measurements. In general, however, the existing research agrees that DCIS patients have a good long-term prognosis from physical, emotional and clinical perspectives. In other words, DCIS patients were found to have physical and emotional functioning that was in the normal range for healthy women, no matter what treatment option was chosen (e.g. lumpectomy with radiation therapy and mastectomy) (Id.). In fact, patients treated by mastectomy had slightly higher scores than those treated with lumpectomy followed by radiation, probably due to the fact that mastectomy patients do not experience any of the side effects associated with radiation therapy (e.g. fatigue, depression) (Tuttle et al. 2009). In summary, an increase in the availability and use of screening mammography has led to an increase in breast cancer diagnoses, with DCIS being the most common non-invasive breast cancer diagnosed. In fact, DCIS makes up 20% of all new breast cancer diagnoses. While the number of DCIS diagnoses is increasing, the amount of existing research on DCIS is not growing as quickly; actually, there is a severe lack of research on DCIS diagnoses and treatment and much more is needed. The research that does exist shows that mastectomy and lumpectomy with subsequent radiation therapy have an equally high survival rate of 96% and above; however, lumpectomy with radiation results in a slightly higher rate of recurrence than mastectomy. Therefore, mastectomy is becoming the treatment option that is chosen in a majority of DCIS cases. Impact of Treatment on the Individual and the Role of the Nurse in the Process Women with DCIS undergo physical change or changes that may not be easily acceptable by themselves or the people surrounding them. It was not surprising that in a study conducted by (Sackey, Sandelin, Frisell, Wickman, and Brandberg, 2010) investigating health-related quality of life or HRQoL) among 162 women subjects, 47 who had mastectomy and also had immediate breast reconstruction (IBR), 51 sector resection, and 64 sector resection and postoperative radiotherapy. The study established there was a very satisfactory HRQoL in the long term not unlike women in general situation. Those who had mastectomy and IBR scored significantly higher on physical functioning and bodily pain than the two groups. They were able to note, however, that body image negatively affected in mastectomy and IBR patients and recommended that more extensive preoperative information about changes in body image after surgery should be provided to the patients. Among the psychosocial experiences of DCIS patients include self-consciousness, feeling of less physical attractiveness, dissatisfaction, less feminine, difficulty in seeing the naked self, less sexual attraction, avoidance of people, see body as incomplete, dissatisfaction with the body, and dissatisfied with scar (Sackey et al, 2010). These feelings and experiences, however, were not seen as prevalent although experienced by DCIS patients. Sackey et al (2010) also recommended to DCIS patients IBR with implants as this was seen suitable for implant-based reconstructions. For unsatisfactory outcomes of the cosmetic occurred, other models of reconstructive techniques were also offered such as immediate flap reconstructions In another study that followed 50 women newly diagnosed with DCIS over the first year post-diagnosis found that anxiety and depression reduced significantly from baseline to 6 months; there was a relatively stable body image distress although noted as extensive for some women; and that those who underwent mastectomy with immediate reconstruction had significantly greater body image concerns. The study concluded that DCIS patients experience psychosocial distress that although transient, may be extensive and prolonged. It recommended that psychosocial support should be provided to help DCIS patients better adjust to the diagnosis, treatment and long-term implications (Kennedy, Harcourt, Rumsey and White, 2010). Meanwhile, in a comparative study breast cancer patients and DCIS patients with regards to HRQoL, impact of the disease, and understanding of diagnosis of patients, it was found that the DCIS group reported better physical health, better sex life, and better relationships with friends, acquaintances than those with invasive breast cancer. Better prognosis, however, had comparable perceptions of the risk of recurrence and dying of breast cancer (van Gestel, Voogd, Vingerhoets, Mols, Niewenhuijzen, Repealer van Driel, van Berlo and van de Poll-Franse, 2007). Health care professionals including nurses have been found to provide a conflicting if not varied opinions about patients with DCIS with regards to condition, styles of communication, and preferred terminology. This has influenced the DCIS patients’ perception and understanding of the disease (Kennedy, Harcourt, & Rumsey, 2008). There was diverse terminology and difficulty of communicating DCIS among health care professionals including nurses that is believed to influence patients’ perceptions and experiences. This meant that DCIS is a challenging diagnosis for professionals to manage as there was uncertainty surrounding the condition. As Kennedy et al (2008) suggested: anecdotal evidence suggests that many patients focus on the term ‘carcinoma’ or ‘cancer’ when they are diagnosed with DCIS, both of which are associated with metastatic disease and mortality. The general inconsistency in language and terms used in DCIS has been reported to leave patients confused. From a patient-centred perspective it is imperative that the language health professionals use to explain DCIS is understandable, coherent and consistent, so that patients can clearly comprehend the condition and the rationale for the recommended treatment (92). It was noted however that in describing DCIS as abnormal cells, an abnormality of a pre-cancerous condition, healthcare professionals lessen the impact of the diagnosis among patients. In addition, terms such as “early” and “non-invasive” also minimize understanding of the risk and seriousness of the diagnosis (Kennedy et al, 2008) Conclusion Like any kind of disease, health care professionals and patients with DCIS may find challenges towards full understanding of the disease from pathology to management of disease and patient. This is not surprising even on the inconsistent understanding and communication imparted by the health care professionals themselves due to the wide range of diseases that they encounter daily and the obvious need for more specific knowledge about the disease. There are situational cases that need to be understood about care and management as well as impact on individual patients and it is important that consistent knowledge and communication be imparted with patients so as to reassure as well as educate them about their situation. Likewise, patients should be informed of recommendation for improved post-treatment HRQoL as well as provided psychosocial support in order to lessen negative experiences. Even prior to treatment, options should be presented to patients as well as risks and other expectations in order to lessen unnecessary stress and negative experiences. As a professional that directly interacts with patient and their immediate family or caregivers, the nurse has a vital role in the provision of correct information of DCIS as well as reassure them of risks or the lack of it. They also can provide psychosocial readiness for diagnosis and post-treatment expectations. References Alderman AK, Hawley ST, Walje J et al. 2008, ‘Understanding the impact of breast reconstruction on the surgical decision-making process for breast cancer’, Cancer, vol. 112, no. 3, pp. 489-94. Claus EB, Petruzella S, Carter D & Kasl S 2006, ‘Quality of life for women diagnosed with breast carcinoma in Situ’, Journal of Clinical Oncology, vol. 24, no. 30. Claus EB, Stowe M & Carter D 2001, ‘Breast carcinoma in-situ: Risk factors and screening patterns’, Journal of the National Cancer Institute, vol. 93, pp. 1811-17. 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Zuckerman D 2009, ‘DCIS: mostly good news’, Cancer Prevention and Treatment Fund. http://www. Stopcancerfund.org/posts/145. Read More