In this essay, a patient’s journey from diagnosis to completion of treatment will be discussed. The topics dealt with will include causes, to life after treatment. The text below will suggest the best possible actions and care for the patient.
Etiology and Epidemiology
Intraductal Carcinoma of the breast is classified as an in situ tumor where the lining of the duct mutates and become cancerous but does not spread (Cancer Research UK, 2017). In 2015, this accounted for around 7,900 female and 30 male breast cancer cases (Cancer Research UK, n.d). Malignant cell development in breast cancer has been linked with the lifestyle of an individual. For example, the medication they take such as the contraceptive pill or hormone replacement therapy; a lack of exercise and obesity (Cancer Research UK, 2017). Family heritage and genetics can also be a factor in cancerous cell formation; where a group of cells are already partially faulty and need fewer mutations for malignant cells to be created (NHS, 2016). One group of people known for inheriting the faulty BRCA 1 or BRCA 2 gene are the Ashkenazi Jewish population (Harmer, 2016). A final cause to discuss is age. If a female patient is 50, they are most likely to be going through the menopause which increases the risk of cancer. NHS (2016) statistics state “8 out of 10 cases of breast cancer occur in women over 50”.
Presentation and GP
A patient’s journey begins at presentation. Two paths can lead an individual to specialists for diagnosis. An initial appointment with a General Practitioner (GP) is often where a cancer is discovered as symptoms are experienced. These could include lumps in the breast or axillary nodes, breast pain and nipple abnormalities (Koo et al., 2017). To expand, Sibbering & Courtney (2015) state that the nipple may be discharging blood and be inverted. Using these signs, a GP would follow the NICE guidelines (National Institute for Health and Care Excellence, 2015) and complete a checklist to see if the patient needs a referral to a specialist. If appropriate, an individual should be seen within two weeks of a referral (Cancer Research UK, 2017). Secondly, a female between 50 and 71 years old should be invited every 3 years to take part in the national breast screening program (Public Health England, 2015). During a visit, a mammogram is taken. Kinsey-Trotman & Fosh (2016) show that at least 20% of tumors are caught through the screening program. Similarly, Wexelman et al. (2017) support that many tumors are caught during screening, even precancerous or low stage cancers are captured, improving survival rates. A patient will be referred to a specialist for more testing if needed after screening.
Diagnosis and Staging
Further investigations take place following a mammogram, these may include other diagnostic imaging. Alongside this, a needle biopsy will be taken where a collection of core tumor cells sent for analysis. Also, biopsies could be gathered from the sentinel lymph node in the axillar to test for nodal involvement (NHS, 2016). A hormone test may be conducted to see if a tumor can be treated and contained through this method of treatment.
After receiving test results, TNM staging from images is used in to evaluate the size of a primary tumor (T) to recognize if there is nodal involvement (N) and to see if there are metastases (M). In this case, T1N0M0 means there is a primary tumor of less than 20mm in diameter (Cancer Research UK, 2017). The sample of cells is taken to histology for analysis by microscopic testing. In this instance, a grade 3 cancer is diagnosed: this means the tumor has very differentiated cells compared to normal cells. The carcinoma is aggressive and developing quickly (NHS, 2016), which could change the course of action for treatment.
Principles and Methods of Cancer Management
Following diagnosis, a case is passed through to a Multidisciplinary Team (MDT). A MDT includes surgeons, radiographers and specialist nurses to help plan the best course of treatment for a patient (Kesson et al., 2012). At this stage, the patient’s disease would be treated radically in the hope that the cancer does not return. A radical surgical option is a mastectomy. These management options are suggested in patients at high risk of recurrence, for example, those with the BRCA 1 or 2 gene (Senkus et al., 2015). But if a patient wants to have this procedure done for other reasons the MDT should take their preference into consideration. Polsky et al. (2002) shows the positive impact that patient choice has on an individual’s health and wellbeing. In this case, there is little information suggesting the patient has a high risk of recurrence therefore, the procedures above would not be recommended and a breast conserving surgery would be a more viable option (Senkus et al., 2015). However, Sibbering & Courtney (2016) propose that a mastectomy is the most effective treatment but agree it is the patient’s choice. Advancements in restructuring technologies, for example onco-plastic surgery mean an individual may favor a mastectomy. In addition, Whelan et al. (2015) reveals the majority of people with stage one breast tumors will have a cancer management plan which involves a combination of treatments. It is suggested that this patient has a lumpectomy with whole breast external beam radiotherapy (WBRT). Senkus et al. (2015) state that in most oncology departments it is compulsory to have radiotherapy after a breast-conserving surgery for the benefit of the individual as it reduces the potential return of the cancer. Furthermore, to reduce cardiac dose and avoid causing cardiovascular disease, in left-sided breast cancer patients, deep inspiration breath-hold can be used (Van Haaren et al., 2017). Czeremszynska et al. (2016) find that using this procedure results in a 20% reduction in the dosage to the heart which benefits the patient by preventing radiation-induced side effects. However, some patients are not able to hold their breath long enough for the treatment to be effective (Czeremszyńska et al., 2017).
This patient could present with a variety of hormone positives and negatives after testing. If the patient is estrogen receptor positive (ER +) survival rates increase by 4% (Predict Breast Cancer, n.d) as there are more treatment options. Similarly, there is an increase in survival rates if a patient is human epidermal receptor positive (HER2 +) and progesterone receptor positive (PR +). A hormone treatment appropriate for the patient is aromatase inhibitors instead of other treatments such as tamoxifen due to the individual’s menopausal status (NICE, 2018). Margolese et al. (2016) support the use of Arimidex and show the benefits for postmenopausal women. However, Forbes et al. (2016) state there is little difference between the two and an extensive study needs to be conducted to see the true effects. The NICE pathways (2018) show that a patient who is advised to take endocrine therapy for 5 years, is over 50 years old, has no nodal involvement and a tumor size less than 3cm, should be considered for partial breast radiotherapy (PBRT), instead of WBRT, to reduce the risk overtreatment (Cutuli, Bernier & Poortmans, 2014). However, Szumacher et al. (2016) found that patients preferred having WBRT to PBRT due to the different side effects that each procedure has. On the other hand, Livi et al. (2015) conducted a scientific study and found the results of each treatments recurrence rate similar but stated PBRT caused fewer and lower risk side effects. All of this shows the controversial mix of ideas, findings and opinions making choosing the best treatment difficult.
Another option is chemotherapy; this can be neoadjuvant or adjuvant to surgery and radiotherapy. Chemotherapy is a systemic treatment; effecting the whole body not just the tumor (NHS, 2017). Normally, chemotherapy is used to reduce the size of the tumor and treat metastases (Symonds & Walter, 2012). This patient has a grade 3 tumor, which is aggressive (NHS, 2016), so chemotherapy could be used. Whereas, if it were a grade 1 tumor, chemotherapy would not be the first option. Also, this treatment is usually used for those with a strong or triple negative hormone response (Derks et al. 2018). Therefore, chemotherapy is not as viable as it would cause many unnecessary side effects.
Many side effects are seen due to treatment, especially during radiotherapy. A radiographer everyday will communicate with the patient giving advice and support. Firstly, a common physical side effect is erythema which worsens with dose given (Badenchini et al., 2017). Radiographers could suggest many options; the Society of Radiographers (2015) recommend aqueous cream instead of soap for the irritation, sodium lauryl sulphate free moisturizer for comfort and loose cotton clothing to prevent friction. Not only are the physical impacts important but making sure that the patient has a comfortable and supportive atmosphere to walk into every day is essential. Communication is a key factor in patient care; it should be age, culturally and knowledge appropriate considering learning deficiencies, language barriers and disabilities so all have access to their treatment (NICE, 2016). Non-verbal communication is also picked up by a patient (Health Care Professions Council, 2013). If you use non-verbal communication effectively, for example a smile and arms uncrossed, an individual can reflect your attitude, increasing their mood and making the daily exposure more successful. Active listening and observation are also critical to a patient’s journey as if they feel the validated and supported, they will relax and treatment will be more beneficial (Simpson, Truant & Resnick, 2014). If a radiographer uses these skills a patient is more likely to open up about their issues and side effects meaning they can have a more holistic view of the patient’s situation and they are then able to refer the individual to others for more assistance.
Potential Psychosocial Issues
An individual could be signposted by a radiographer to a support team, for example the Macmillan Center, for the psychological issues which arise during treatment. This could be because of an influx of strong emotions including anxiety, depression, anger and shame for both patients and their families (Macmillan, 2017). If this patient has surgery, self-esteem and sexual function may affected (Jun et al., 2012). This could be due to the disfigurement which occurs as a result of their treatment which effects the perception of their body image (Park et al., 2015). Not only this, when patients receive a cancer diagnosis, they may fear death and the consequences for their families (Rocha-Cadman, 2014). Furthermore, during a patient’s journey, the financial burden can increase for every person involved. An individual will have to travel into the hospital and they may have to pay for painkillers or medication (Pisu, 2014). Finally, people may lose the hope they have in their faith and the meaning of their life (Yun et al., 2017). At this point, a patient may have been seen by many members of the MDT including a group psychologist and a chaplain, if they choose. All these psychosocial issues show the need for integrated centers within hospitals as patients need as much support as they can get (Weis, 2015). Grassi et al. (2015) illustrate that good psychological, emotional, financial and spiritual support leads to lower mortality rates during and after treatment.
Clinical Follow Up, Support and Life after Treatment
Following completion of treatment, regular physical examinations, mammograms and blood tests are recommended for patients to attend (Khatcheressian et al., 2013). These should take place annually for at least 5 years (Cancer Research UK, 2017). During the first check up a patient will receive a care pack containing information on what the tests involve, symptoms to be aware of in case of recurrence and telephone numbers for clinical departments if they have any worries (Cancer Research UK, 2017). Patients are also advised to join external support groups including Maggie Centres, as life after treatment is found to be challenging by patients. The fear of cancer returning will impact an individual and their family even after the completion of routine checks, many years later (Sharpe et al., 2018). Survivorship care plans are also put into place to get patients back to their normal routines. Palmer et al. (2015) demonstrate the positive effect of survivorship care programs have in getting cancer patients back on their feet and motivated again.