This essay is patient focussed and based on a real service user and her medical diagnosis and her journey through this experience. For the purpose of this essay I have gained verbal consent from a patient I cared for during one of my placements, and to protect the patients confidentially I have changed the patient’s name and their relative’s names.
To also make this essay easier to read and understand I have paragraphed each different topic and attached subheadings.
Patient history
During my last placement I began to care for a 53 year old lady called Ann Dingle, Ann had been diagnosed with breast cancer 3 years ago, aged 50. And aged 36 Ann was also diagnosed with type 2 diabetes, which she manages herself using an insulin pen. On Ann’s mother’s side of the family, there is also a history of ovarian cancer, which started from a diagnosis from her grandmother who passed away due to the diagnosis of ovarian cancer which was found to late. Many years later sadly both Ann’s mother (Catherine) and her younger sister (Carol) had also been diagnosed with ovarian cancer. Ann’s mother manged to fight the cancer battle and got the all clear 12 years ago, Ann’s younger sister however who was diagnosed 5 years ago had been given the all clear up until last year when a tumour appeared on a check-up ultra sound scan at the hospital. Carol had been diagnosed with ovarian cancer for the second time, and was told the tumour was too enlarged to remove. Carol now has regular treatment of chemotherapy to help shirk the tumour.
Breast cancer illness causes / effects
Breast cancer is the most common cancer in the UK, it begins when uncontrolled growth cells in the breast which begin to separate and breed in an abnormal way causing a tumour (Breast Cancer Care, 2016). This causes abnormal changes in the genes which regulate the growth of cells and keep them healthy. Breast cancer can begin in the cells of the lobules, these are the milk-producing glands, or can begin in the ducts, these are the passages that drain the milk from the lobules to the nipple (Breastcancer.org, 2016).
There are many different causes / risk factors of why one person may develop the illness, age increases the risk and is most common in women over 50 and in woman who have experienced menopause. Exposure to oestrogen, the more oestrogen your body releases the greater you are at developing the illness. Being overweight is also a risk factor especially if you have experienced menopause, this produces more oestrogen in the body. Hormone replacement therapy (HRT) can be an increased risk of breast cancer. Both HRT and oestrogen-only HRT can increase your risk of breast cancer (www.nationalbreastcancer.org, 2015). A family medical history of breast cancer or ovarian cancer gives you a greater risk of developing the illness. A family history of ovarian cancer gives people a greater risk factor of developing breast cancer, this is because of mutations in the BRCA1 or BRCA2 genes, have an increased risk of developing ovarian and breast cancer (Ovarian-cancer.canceraustralia.gov.au, 2016). New research has also shown that women who take the contraceptive pill have an increased risk of developing breast cancer (www.nationalbreastcancer.org, 2015).
The risk factors for Ann, being an older lady in her 50’s was a risk factor. Her mother’s family history of ovarian cancer any first degree or second degree family member who has been diagnosed with ovarian cancer at any age, increases the development.
Ann’s own medical history of type 2 diabetes was also a risk factor, studies have shown that woman are up to 20% more likely to develop postmenopausal breast cancer than older, non-diabetic women, women with type 2 diabetes have a greater risk of developing breast cancer (Diabetes.co.uk, 2016).
Admission to GP
It was Carol, Ann’s sister who advised Ann to seek medical advice when she started experiencing bloodstained discharge leaking from her right nipple, and an enlarged change in the size of her right breast. Ann had been experiencing these symptoms for serval weeks but couldn’t come to terms with the fact breast cancer could be back in the family now effecting her. Ann first noticed a change in her right breast when in the bath, the change in size described by Ann was “dramatic” but Ann thought it was just swollen and put it down to pre-menopause symptoms. Serval weeks passed with no change in Ann’s right breast getting any smaller, instead now a bloodstained discharge was leaking from her right nipple causing Ann to feel worried and distressed. Ann then took matters into her own hands by consuming alcohol every other day to psychologically make herself feel better.
Once Ann’s sister had found out about Ann consuming regular alcohol she decided for Ann’s health to tell her mother everything. After a family discussion between Ann, her mother and her sister about all the different signs and symptoms, Ann had been experiencing her and her family all agreed the best thing to do was to make an appointment with her GP.
Investigations undertaken for diagnosis
Ann made an appointment, and had been to see her GP where she was examined for the signs and symptoms she was experiencing with her right breast. Ann’s GP also found a small lump under her armpit located on her right side, which Ann didn’t know about. Ann was then referred by her GP using a suspected cancer pathway referral to a breast cancer clinic. She was then seen within the national target for cancer referrals within 2 weeks (Nice.org.uk, 2016).
At the breast cancer clinic, Ann had both of her breasts screened using an X-ray called a mammogram, this X-ray checks for any cancerous cells in the breasts (www.nationalbreastcancer.org, 2015).
Ann also underwent further tests including a breast biopsy, this is an examination that removes tissue or fluid from the expected lump area. The removed cells/tissue are examined under a microscope by a pathologist to check for the presence of breast cancer. There are three different types of biopsies Fine-needle aspiration, core-needle biopsy and surgical biopsy. Ann underwent the fine needle aspiration biopsy, this is a procedure where the lump should collapse, and this should happen once the fluid inside the lump has been drawn using the fine needle. But for Ann, an ultrasound was also needed to help the doctor guide the needle to the precise place, the ultra sound uses high-frequency sound waves to produce an image of the inside of the breasts (www.nationalbreastcancer.org, 2015).
Once the procedure was finished Ann was sent home, and was contacted by her GP 4 working days afterwards to make an appointment to see her GP about her results. All lab results from the biopsy come back on a pathology report, this is a report with all the findings showing if your suspected area is cancerous from your biopsy test (www.nationalbreastcancer.org, 2015).
Sadly Ann’s GP broke the news that her lump was cancerous and further lab tests would be needed for the right treatment.
Treatment
Two tests where preformed a hormone receptor test (testing the tumour cells) and the HER2/neu test. A hormone receptor test is a protein located within the cell, most breast tumours contain hormone receptors in large amounts. If hormone receptors are present, oestrogen and progesterone can develop the growth of the cancer. Some hormone-dependent cancers can often react well to hormone therapy. If oestrogen receptors (ER) or progesterone receptors (PR) are present, then hormone therapy would be ineffective. Knowing if cancer cells have hormone receptors can be valuable to your treatment plan. For patients who test positive for oestrogen and progesterone receptors normally have a better prognosis for survival. The other test preformed in the lab is the HER2/neu, this consists of four tests.
The IHC test, looks for any excess HER2 protein in cells. An outcome of 0 or 1+ shows there is no excess, 2+ is borderline, and 3+cells test positive for HER2. And the three final tests all examine if the cells contain copies of the HER2 gene. Once the tests where completed Ann had to return home and wait for another call off her doctor until her results were ready. These results took a little longer and Ann was contacted 2 weeks later by her GP. Her results on her pathology report showed, her breast cancer was positive for both HER2 protein overexpression and HER2 gene amplification, this type of cancer grows and spreads more quickly than other cancers (www.nationalbreastcancer.org, 2015).
Ann’s pathology report also shown that Ann had invasive stage 3 (3c) breast cancer, this means the cancer cells will have travelled to either the underarm (axillary) lymph nodes, which in Ann’s case the lump was found by her GP under her arm, or the cancer cells could even spread to the breast bone (sternum) or the collarbone. Stage 3c invasive breast cancer means the tumour can be any size but only contained in the breast tissue. Lymph nodes can vary and can be found in either your collarbone, breast nodes or underneath the arm (Verywell, 2016).
Ann’s GP then discussed the right recommend treatment for her, surgery was the first step in Ann’s treatment. For breast cancer treatment surgery is the most common treatment, surgery involves removing the tumour and the margins surrounding. The surrounding margins are removed for tests to see if the cancer has spread. There are also different types of surgery for breast cancer treatment, Lumpectomy, this removes the tumour and the margins known has the healthy tissue. Mastectomy this removes the entire breast and Lymph Node Removal & Lymphedema this surgery removes lymph nodes to see if the cancer has spread and if so how far.
Ann’s GP also discussed health promotion and risk factors with her, physical inactivity and dietry have been linked to different types of cancers including breast, and are important to cancer control. Regular exercise and maintaing a healthy body weight while consuming fresh fruits and vegetables will considerably lower the risk of developing cancer. Ann was advised to look after her before, during and after surgery. Ann was also advised to lower her alcohol intake or stop completely has this is also a big risk factor to developing cancer (Who.int, 2016).
Outcomes and expectations were also discussed, Ann was told her new breast which she will get from her reconstruction may not look and feel the same as her other breast, and can sometimes be less sensitive. Serval visits to the hospital after her procedure for further operations may be needed to get the best result (Breast Cancer Care, 2016).
Ann and her doctor agreed that a Skin-Sparing Mastectomy for treatment would be the best for her, this is removal of the whole breast, nipple, areola and sentinel lymph nodes, this procedure does not remove the healthy breast tissue so the patient can have reconstruction.
Within a couple of weeks Ann had her surgical procedure completed, on the day of the procedure Ann was given a general anaesthesia to help her fall asleep. During the procedure the surgeon made a small incision around the areola on Ann’s right side so the breast tissue could be removed, the nipple and the areola where also removed during this procedure (Mastectomy, 2016). The reconstructive surgeon then used the remaining skin tissue to reshape and rebuild Ann’s new breast, Ann had synthetic silicone implants to rebuild her breast.
After Treatment
After surgery, Ann was admitted to a post-op ward where she was prescribed Herceptin for her HER2-positive breast cancer. A nurse then inserted a cannulation into Ann’s vein for an IV drug to flow through. The drug Herceptin, this is a manmade protein to treat the immune system protein and can only be given through veins (Cancer.org, 2016). A side effect of Herceptin can be heart damage, which can lead to congestive heart failure, this is where the heart doesn’t pump the blood the way it should. The risk of this side effect happening is higher in patients who are taking chemo drugs such has Epirubicin, this drug can cause heart damage and normally before being prescribed the drug an echocardiogram should be done on the patient to make sure their heart is ok (Cancer.org,2016). Ann was also given a fabric-covered temporary prosthesis known as a (sofie or cumfie), this is usually given to patients after breast surgery has the chest can feel sensitive and sore from surgery.
Ann spent the night on a postop ward and was monitored. The following day Ann was shown how to manage her drainage tubes which were inserted into her new breast, these drainage tubes are removed on a postop visit (Mastectomy, 2016).
Ann was picked up from the hospital by Carol and taking back to her mothers house where Carol and her mother where going to look after Ann till she felt stronger again. Ann was given prescribed Tramadol a painkiller from the doctor at the hospital to take home, Tramadol is a slow release 12 hour painkiller. Ann was also given an immediate release Tramadol for extra pain, 400mg is the max dosage that can be taken in a day while on Tramadol (painkillers, 2016).
Follow up
Since Ann’s treatment she has been back to the hospital and had her drainage tubes removed from her breast. Ann has also underwent another operation to reshape her silicone breast, which she is now delighted with. And has had her follow up appointment, this consisted of a physical examination of the underarm, neck, breast area’s and chest. A mammogram was also preformed and came back with some abnormalities to the left side of her breast in the milk ducts. Ann has since had another biopsy and is awaiting her results from her GP.
Reflection
Reflecting back on having the opportunity to be involved in Ann’s care was a big eye opener, I am very grateful she allowed for me to go through this journey with her and discuss her personal medical history. I feel I have learnt so much from doing my own research on the illness, and feel I have better understanding on cancer cells and how they start and form which lead to them spreading. In conclusion for my research there is no definite cause to breast cancer and why it happens, but there are ways people can reduce the risk of developing the illness.
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