CONTINUING MEDICAL EDUCATION
ARTICLE

 

An approach to the management of locally advanced breast cancer: Part 2

 

 

K Hill

RN. Netcare Christiaan Barnard Memorial Hospital, Cape Town, South Africa

Corresponding author

 

 

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ABSTRACT

Caring for a patient with locally advanced breast cancer requires a multidisciplinary approach, whether cure or palliation. Patient expectations need to be discussed, while alternative and holistic approaches help to reinforce the patient's belief that their decision regarding care is correct. It is important to recognise that a patient's decision to choose 'no treatment' should be treated with respect. Psychological support and care are vital, requiring a non-judgemental relationship built on trust.

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The challenges of caring for a patient with locally advanced breast cancer (LABC) are multifaceted and need a multidisciplinary approach. It is important to ascertain whether the intention of treatment is to cure or to palliate and these expectations need to be discussed with the patient.

Alternative and holistic approaches can help the patient to feel comfortable with her decision regarding treatment and care. In some cases the best option is 'no further treatment', a decision that many medical professionals find difficult to accept, but that should be respected if appropriate.

The first step is to build a relationship of trust. Looking after patients with advanced disease is emotionally challenging. If family members and friends are involved, it ensures that there is a solid support structure that allows people to have 'time out' from the caring process occasionally.

Psychological support and care are paramount and require a non-judgemental approach. Reading the responses of the patient and family with regard to various aspects of the disease needs experience. It is not uncommon for family members, and even patients, to be uncomfortable with wounds and bodily functions. Helping people to overcome these fears can be challenging and rewarding. However, nursing staff need to know when to stand back to allow families space to cope with the situation. Palliative caregivers are most important with regard to this aspect of care, which can be linked to the management of pain and the late stage of care.

Once a relationship of trust has been established, the nurse needs to assess the patient's level of understanding, support structures and financial resources. Having insight into these aspects will ensure patient-specific and focused holistic care.

 

Pain management

Pain is an important factor in advanced breast cancer and requires continuous monitoring and assessment. Involving support services such as hospices will ensure that the patient receives excellent pain management and the entire family receives emotional support during this challenging time. There are many options for pain management, which should be discussed with the treating physician. Pain control generally follows a stepwise approach using a combination of opioids, non-opioids, such as paracetamol and non-steroidal anti- inflammatory drugs, and medications for neuropathic pain, when necessary. Pain is a subjective experience and, as such, difficult to evaluate. Therefore carers must be able to perform a comprehensive pain assessment that includes more than the patient's reported pain. Other subtle indicators such as mood changes, depression, and changes in how the patient feels regarding the disease need to be recognised and acted upon. When opioids are introduced, patients and their families might believe that death is imminent. Pain management, especially the level of pain control, needs to be explained.

 

Wound management

Caring for breast cancer wounds can be challenging. Wound care is a manageable problem, with numerous resources available. Any strategies in this regard should be discussed with the multidisciplinary team. The role of systemic treatment and radiation therapy is discussed in Part 1 of this article.^[1]

A fulminating wound is a particularly sensitive and difficult matter. Patients are often embarrassed by such a wound and its odour. It is the most visible sign of the disease and not only affects the patient's body image but also the patient's relationship with family and friends. A nurse may need to visit a patient a few times to establish mutual trust before the patient allows her to see the wound.

Secondary wound infection is an important potential complication. One way of minimising this risk is to train a limited number of people with regard to home wound care. This prevents exposure to nosocomial infections and can help to reduce the risk of treatment modalities being altered by nurses who may differ in their wound care management practices. However, it is sometimes problematic to find a suitable person - someone who is comfortable with the task and with whom the patient feels comfortable. The following are some practical considerations:

Wound odour. This is probably one of a patient's worst problems. While the wound can be packed with dressings and covered with clothing, the odour is very difficult to hide. Putting a small bowl of vanilla essence in the room or burning eucalyptus oil or a citronella candle will make the odour less obvious during dressing changes. If the patient finds that the odour is still there, in spite of the new dressing, a small drop of eucalyptus or tea tree oil can be applied to the outer corner of the outer part of the dressing before the wound is closed. To prevent any possible skin irritation, ensure that this drop of oil is not placed where it can come into contact with the skin.

Draining wounds. There are various options for draining wounds based on the volume of exudate. There are dressings available that prevent excoriation of the surrounding skin and leakage through clothing. Stoma bags can be used for small wounds that have a high drainage rate. Slightly larger wounds can be managed using an appropriately sized disposable nappy, which not only allows for the skin to stay dry but also tucks quite nicely into a bra, thus ensuring that the dressing does not fall off or slide down. Large wounds can be well managed using abdominal swabs. Some patients report that these can be washed and then re-used for a few months. As many of the patients have skin excoriation caused by radiation therapy, plasters are not advised. Elastomesh® keeps the dressing in place, as does a comfortably fitting vest with a piece of trouser elastic around the chest.

 

Conclusion

Human nature is complex and people's responses to situations can vary greatly. This places a great deal of responsibility on the care- giving team to ensure that care programmes meet unique patient needs. With the rising costs of healthcare and increasing medico-legal awareness, many patients are looking for a more holistic approach to their healthcare. Healthcare workers need to embrace this approach and make an effort to integrate medical and nursing needs with those of the patient, but this may be challenging and require a degree of negotiation. The ultimate aim is to provide the necessary care in a calm and relaxed setting, while simultaneously making the patient feel as if they have been an integral part of the decision-making process.

Acknowledgement. I wish to thank Sister C Grehan, Advanced Wound Care Specialist, Groote Schuur Hospital, Cape Town, South Africa for her input.

 

Reference

1. Govender P. An approach to the management of locally advanced breast cancer: Part 1. S Afr Med J 2014;104(5):382. [http://dx.doi.org/10.7196/SAMJ.8245]        [ Links ]

 

 

Corresponding author:
K Hill
(karen.hill@netcare.co.za)