Beyond Breast Cancer Treatment, What’s Next?

Four years after having a mastectomy for ductal carcinoma in situ (DCIS), my patient, Madam Lim (not her real name) came in for a routine followup visit.

 

She requested to withdraw her CPF savings on medical grounds. I told her she would not be eligible, since she was not going to die from DCIS. Unconvinced and terribly fearful for her state of health, she was unwilling to continue working and yearned to focus on other life pursuits.

Medical school may teach us that a DCIS patient will require surgery, hormonal therapy and perhaps radiotherapy. However, it does not provide insights into a patient's fears and emotional states, postdiagnosis and post-surgery.

Surgeons often shoulder the responsibility of maintaining a professional opinion, free from emotional bias, in order to render effective treatment to our patients. Yet, not addressing their fears may constitute failing in our duties as caregivers.

Caring for Their Emotional Needs

 

 

In the previous article, Dr Yeo Wee Lee spoke about a multidisciplinary approach to cancer management. While we strive to achieve holistic treatment for our cancer patients, we may fail to take their emotional and psychological wishes into treatment plans. Our duty to patients no longer ends with just the administration of medication and a successful surgical procedure.

In the October 2011 issue of the Wall Street journal, Melinda Beck explores the psychosocial aspects of breast cancer survivors after treatment in her article, 'The new front in breast cancer: After treatment ends'. In the article, Carie Capossela, 43 years old, who has been free of breast cancer for the past 10 years shared that "... the next challenge after diagnosis is when the treatment ends. The reality sets in that you have to live with this the rest of your life and the safety net is gone. That's when you really freak out."

Patient Empowerment Model of Care

This idea is supported by the study released by the Susan G. Komen® organisation that advocates survivorship care planning (Figure 1) and identification of distress in patients.

The organisation advocates a patient empowerment model that is described as being “founded on evidence that people affected by cancer can become informed, take action and make conscious changes within the context of a supportive community that can lead to improved quality of life and enhanced possibility of recovery.” According to Susan G. Komen®, the patient empowerment model is an evidence-based concept that “combines the patient’s will with the physician’s skill, to improve the cancer survivor experience by reducing the three most significant psychosocial stressors that cancer patients face: unwanted aloneness, loss of control and loss of hope.”

Some of the areas highlighted in the patient empowerment model include quality-of-life scores after surgery or systemic therapies such as hormonal therapy, psychological distress of cancer patients and supportive care, symptom control, and fertility and sexuality issues, which are more prominent in younger patients.

The same study discussed some distress symptoms that clinicians may or may not be trained to recognise as tell-tale signs. As primary care providers, the general practitioners may be well placed to identify and manage these symptoms (Figure 2).

 

The Beginning of Survivorship Care

Healthcare professionals are gradually learning to hear our patients out rather than insist that they only heed our advice. Our treatment regimes are tailored to individual patients and their unique psychosocial situations.

Apart from medical treatment, looking into alleviating relevant side effects can be as crucial. For example, to lessen severe emesis during chemotherapy, patients are prescribed a cocktail of steroids that are given together with chemotherapeutic agents, which can cause weight gain. Present-day research efforts push boundaries to develop agents that deliver the same impact to cancer cells, with lesser side-effects (e.g. weight gain), thereby enhancing the patient's psychosocial well-being.

New research is emerging with a host of findings regarding the benefits of prolonged hormonal therapy; with new emphasis on the alleviation of post-menopausal symptoms from long-term hormonal therapy.

From diagnosis to post-treatment, we now spend more time individually to access the patient’s emotional recovery. There are also new roles added to the patient’s treatment plan to look into these areas such as the breast nurse, the psychologist and the social worker.

For younger patients, challenges with childbirth and fertility rise with age. The field of fertility in breast cancer treatment is gaining importance as patients value not just a cure from their disease, but also a significant post-treatment lifestyle.

 

Support groups play a substantial part in the psychosocial aspect of the recovering patient, posttreatment. They not only help to introduce a new patient to a group of understanding professionals, but also serve to form a new support network for them after treatment. Many of our patients form lifelong friendships, post-diagnosis.

At a stage of infancy in the field of survivorship care, awareness and involvement are good points of foundation. Primary care can also play an active role in the post-treatment care of breast cancer patients: we can all listen to and learn from our patients as well.

 Breast Clinic 5th Anniversary Celebrations  

References 

 

Dr Juliana Chen is the Clinical Director and Senior Consultant at The Breast Clinic @ Tan Tock Seng Hospital (TTSH). She did her post-graduate fellowship training at New South Wales Breast Cancer Institute at Westmead Hospital, Australia. Dr Chen’s area of clinical interests include general, breast and endocrine surgery. She is also actively involved in the TTSH Breast Cancer Support Group.