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Mammography:

A Team Approach to Fighting Breast Cancer

Zapp! Educational Services

Mary Stela Gallegos, ABD, RT (R)(M)

(559) 859-4725

Continuing Education Course

This Photo by Unknown Author is licensed under CC BY-SA

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Mammography: A Team Approach to Fighting Breast Cancer

There are several different objectives in presenting the following material. The first

objective of this course is to provide statistics on breast cancer rates, including race and

ethnicity. Second, is to explain the different roles played by individuals in the detection of breast

cancer ranging from the gynecologist to the chaplain and everyone in between. As part of the

breast detection team, all radiology technologists must be aware of their role and of those on

their team. Last, this course will explore several concerns that patients with breast cancer may

have regarding breast reconstruction.

The objectives for the course will be accomplished by the following:

1. Presenting the statistics of breast mortality rates

2. Explaining the significance and importance of using the team approach for breast cancer

detection

3. Listing and identifying healthcare team members in a woman’s breast care

4. Describing the key roles of team members detecting, treating, and caring for patients with

breast cancer

5. Present and discuss key issues relating to breast reconstruction

The Team Effort

Breast cancer has significant mortality rates and requires an unabridged team effort by

multiple specialties to treat and care for a patient diagnosed with this type of disease. Teamwork

is an ideal method of providing health care. Professional, effective, and proficient teamwork by

all individuals involved provides benefits to team players as well as to the patient. A suspicious

lump or mass may be found by the patient or by the primary provider during a routine clinical

breast exam. As the gatekeeper for the patient’s treatment and care, the patient’s primary care

provider is the first one contacted when a suspicious lump or mass is suspected. The primary

care provider plays a vital role in her healthcare treatment since the patient feels comfortable

with them and trust their judgment. However, other team members assisting the primary care

provider are specialists the patient may see for the first time on a referral basis for the treatment

of her life-threatening condition. Included in the team are mammographers who are also

radiology technologists and have experience with female patients and their breast problems.

Knowledge of what the specialists and other team members do, and how they work

together as a team to provide the patient with the best quality care possible is enormously

reassuring to the patient. The patient may feel scared or intimidated by seeing the other team

members as they are unknown to her. One reason is that the patient is stressed, and the

uncertainty of her condition puts even more stress on her. Therefore, the already stressed patient

is even more overwhelmed upon hearing a diagnosis of breast cancer. That is why the team

approach is so important to a woman faced with a cancer diagnosis.

The theory of a team approach is vital to the success of the treatment plan, quality of life,

and the basic survival of the patient. The combined knowledge, expertise, and the support

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provided by all the specialists and team members in evaluating and treating the patient’s

condition have a significant impact on the patient’s breast cancer management process. The team

approach allows the patient to feel more in control of her own destiny so she can participate fully

as a member of the team rather than a passive recipient of care. Plus, the individual positions

held by each team member play an essential role in the success of the treatment plan.

Consequently, all imaging technologists must be aware and knowledgeable of the variety

of individuals who play a significant role in breast cancer detection. Currently, there are more

than 3 million women who have been diagnosed with breast cancer in the United States

(Cancer.net, 2019). Due to the severity of breast cancer, all efforts, innovative ideas, enhanced

technologies, and strategies must be employed to combat this deadly disease. Applying a team

approach is one such strategy to win the war against breast cancer. This course is designed to

provide this information for all breast cancer detection team members. Plus, it demonstrates how

the team functions at its best and how individual doctors, nurses, imaging technologists, and

other team members deal with breast cancer patients with caring and sensitivity while providing

a high quality of care.

There are many benefits of using the team approach when providing medical care. For

example, communication between team members and the patient is vital (see Chart 1.0). The

American Academy of Orthopedic Surgeons noted that 75% of all “close calls” or “adverse

medical outcomes” are from lack of communication (Ray, 2019). As seen in Chart 1.0, the goal

of teamwork is to enhance patient care by increasing the survival rates of patients with breast

cancer. As the main scope of this course is to address who the team members are and their roles

in breast cancer detection, only a few benefits of teamwork are illustrated in the diagram.

Chart 1.0. Benefits from using team approach (Ray, 2019).

GOAL:

Enhanced patient care

Communication

Reduce Stress

Quick recovery

Reduce errors

Cost effectiveness

Share responsibility

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Breast Cancer Rates

Other than skin cancer, more female patients are diagnosed with breast cancer than any

other cancer. In the United States for 2019, approximately 62,930 women will be diagnosed

with in situ breast cancer, and 268,600 women will be diagnosed with invasive breast cancer

(Cancer.net, 2019). Table 1.0 illustrates that 263,090 new cases were found in 2016, in which

White women had 201,207 cases, Black women had 28,961 cases, Hispanic women had 21,039

cases, Asian/Pacific Islanders had 10,435 cases, and American Indian/Alaska Native had 1,448

cases (CDC.gov, 2016). Chart 2.0 illustrates the same 2016 data but in percentages of new cases

of breast cancer by race: White women 25%; Black women 24%, Hispanic women 19%,

Asian/Pacific Islander women 18%, and American Indian/Alaska Native women 14%. Plus, an

estimated 2,670 men in the United States will be diagnosed with breast cancer. In addition to

these statistics and other estimates, approximately 42,260 deaths (500 men and 41,760 women)

will occur from breast cancer this year (Cancer.net, 2019).

Rate of New Cancers by Race/Ethnicity, Female

Race/ Ethnicity Rate Case Count

White 125 201,207

Black 122.6 28,961

Hispanic 93.7 21,039

Asian/Pacific Islander 92.3 10,435

American Indian/Alaska Native 72 1,448

Total 263,090 Table 1.0 Source: CDC.gov United States, 2016, Rate per 100,000 women

Chart 2.0 Source: CDC.gov United States, 2016, Rate per 100,000 women

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A tumor can be benign or cancerous, but a cancerous mass begins when normal and

healthy cells in the breast start to change and flourish in an out of control fashion. Thus, a mass

or a tumor is formed. Some women may have what is referred to as a benign tumor, which means

the tumor will not spread but may grow. If the patient develops a malignant tumor, it is then

considered cancerous; meaning it can spread or metastasize to other parts of the body and grow.

Breast cancer metastasis occurs when cancerous cells move from the breast to other parts of the

body through the blood and lymph vessels.

The 5-year survival rate is significant because it conveys what percent of people will live

at least five years after their breast cancer diagnosis. The specific percent refers to how many

patients out of 100 will survive. However, it is based on what stage the cancer is at when detected or

diagnosed. Nonetheless, some patients will live and survive much longer as the 5-year survival rate is

only an estimate. Another important fact to know is that the lower the stage of breast cancer, the better

the chances of surviving and living longer. The average 5-year survival rate for women with

invasive breast cancer is 90%, and the average 10-year survival rate is 83% (Cancer.net, 2019).

Figure 1.0 illustrates the survival rate of breast cancer based on the stage of diagnosis.

For example, if a patient is diagnosed with breast cancer, and it is determined the cancer is at

Stage O, then the patient has a 100% 5-year survival rate. However, is the patient is diagnosed

with breast cancer at Stage IV, then she only has a 22% chance of survival after 5-years

(DerSarkissian, 2017). When taking a more in-depth look at breast cancer rates, approximately

5-Year Survival Rates by National Cancer Institute

Figure 1.0 Source: DerSarkissian, 2017

Stage 0: 100%

Stage I: 100%

Stage II: 93%

Stage III: 72%

Stage IV: 22%

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6% of female patients have metastatic cancer upon the initial diagnosis of breast cancer

(Cancer.net, 2019). With the advancement of technology and new treatments, many patients with

breast cancer maintain a good quality of life (at least for some time), even when the cancer is

found at Stage III or IV.

Of significant notice is the fact that the above-mentioned statistics are classified as

averages, and each patient’s risk depends on many factors:

➢ size of malignant tumor

➢ number of lymph nodes with cancer

➢ success of treatment

➢ other characteristics of tumor that impact how quickly tumor grows

As these features vary from patient to patient, it becomes difficult for breast cancer

experts and providers to estimate each woman's chance of survival. Following lung and

bronchus, breast cancer is the second most common cause of death from cancer in women in the

United States (see Chart 3.0). Fortunately, the number of women dying from breast cancer has

steadily decreased since 1989 because of early detection, the advancement of technology and

treatment, and collaboration of all vital team members (Cancer.net, 2019).

31.9

20

11.59.7

6.85

Lung/Bronchus Female Breast Colon/Rectum Pancreas Ovary Copus/UterusNOS

Top 6 Cancers by Rates of Cancer Deaths Chart 3.0

United

States,

2016

Rate per

100,000

women

Source:

CDC.gov

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PRIMARY CARE

DIAGNOSIS, MANAGEMENT, AND REFERRAL

A yearly visit to the obstetrician-gynecologist (OB-Gyn) or internist is routine for many

women. Many women do not have an internist and therefore are referred to an OB-GYN

specialist if they develop a breast problem.

The Obstetrician-Gynecologist role in a woman’s breast care

An obstetrician-gynecologist is a specialist who cares for women and their reproductive

organs. At times, this specialist serves as the patient’s primary care physician for most women

and often is the only doctor that they can visit on a regular basis. The ob-gyn performs a patient’s

semi-annual, annual, physical and pelvic examination, and Papanicolaou (Pap) smear. In

addition, they will also perform a screening breast exam for breast cancer. In the absence of

breast disease, the gynecologist is usually the provider who requests breast-screening exams such

as a mammogram. It is his or her responsibility to be knowledgeable about the various types of

tests and procedures available, and the advantages and disadvantages of each exam. Plus, they

must also be aware of the standard guidelines (frequency) in which these examinations should be

performed. The newest technology, procedures, and development in the area of breast diagnosis

must be part of every gynecologist’s experience and knowledge.

One role for the gynecologist is to inform and to educate their patients about the need for

regular, monthly breast self-examinations. They must also explain the importance of breast

annual exams and mammograms for early detection. A woman’s female hormonal cycle plays a

vital role and impacts her breast tissue. As a result, she needs to fully comprehend these monthly

cycles and changes so that she knows when to examine her breasts. There are many challenges

for women not performing these tests, including the fear of discovering a mass. This is one of the

biggest reasons women do not get their route breast exams and procedures. Other reasons include

This Photo by Unknown Author is licensed under CC BY-NC-ND

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lack of knowledge, the significance of early diagnosis, ignorance of procedural techniques, and

lack of awareness of the prevalence of breast cancer.

The gynecologist is typically the first physician a female patient contact when she

discovers a questionable breast lump or mass. A unique and trusting relationship exists between

a gynecologist and a female patient. It allows the physician to deal with the emotional, physical,

and psychological issues of the patient’s breasts and any associated problems. The discovery of a

suspicious breast lump rouses supreme anxiety, frustration, and fear in women. Therefore, a

gynecologist must sensitively respond to the patient’s breast problems encompassing all aspects

of health and mental wellness. For example, the overwhelming level of stress produced by the

discovery of a suspicious mass must be dealt with as well as the treatment for the actual breast

disease.

After a clinical breast examination of the patient by the gynecologist, the doctor will

determine which definitive treatment of a suspected breast problem is required. First, their

initiated evaluation will either reassure him/her that a breast disease does not exist or prompt

him/her to evaluate the breast mass further with additional procedures. For example, other

additional procedures or options are a mammogram, breast ultrasound, breast cyst aspiration, or

referral to a surgeon who is familiar with breast diseases and the treatments. As part of her plan

of treatment, a female patient will trust her gynecologist and require guidance such as an

explanation of the course of events that will likely take place. If referred to another specialist, the

gynecologist will have to reassure the patient that specialists’ approach is medically sound after

assessment of her breast problem has been identified, and a final treatment plan determined.

While the breast management team is taking care of the patient and her breast issues, the

gynecologist continues to play a significant role by providing resources and information as the

patient/doctor relationship continues.

The Internist Role in a Woman Breast Care

Today, the internist is an expert in charge of the comprehensive medical care of his or her

patients and providing continuous medical care. The internist’s participation in the treatment of

a patient’s breast tissues or breast malignant growth is nonstop, starting before the cancer is

identified and proceeding until treatment is done.

One important role played by the internist is to act as a counselor. The internist will

inform patients on the requirement for breast self-assessment, clinical breast exams, and proper

utilization of mammograms. Plus, they will inform and counsel the patient about different

medications and hormones that may affect her breasts, and the requirement for genetic testing if

there is a family history of breast cancer. Last, the internists will determine if the patient is at a

higher risk for breast malignancy and order the necessary procedures. To summarize, the

internist’s first obligation is to educate (counsel) their patient about breast practices that will

avoid cancerous growth and lead to a quick detection if cancer does develop.

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When a breast mass is suspected, the internist’s first step is to affirm its presence by

performing a physical exam and then has several alternatives to choose from. On the off chance

that the internist feels sure that there are no signs or symptoms of breast cancer, they may opt to

discontinue any further treatment. However, they may feel that an additional follow-up exam

may be warranted once the menstrual cycle has passed. In most cases, the use of mammograms is

suggested as a helpful tool in detecting breast cancer. If he or she is uncertain about the

diagnosis, they may wish to refer the patient to a surgeon for a second opinion.

In selecting a breast surgeon for patient referral, the internist guided by more than the

surgeon’s technical knowledge and skills, he or she must also consider how the individual

woman will relate to a particular surgeon. Each person differs in the extent she wants to be

informed about the many surgical options now available. Some women with their family

members wish to play an active role in planning treatment, whereas others prefer not to have to

make a choice. They defer their choice to the provider. It is important for the internist, who

usually knows the patient best, to consider her preferences and recommend a surgeon. It is also

his or her responsibility to advise the surgeon as to the woman’s feelings. The surgeon and his

colleagues in the breast management team will usually provide technical information regarding

the woman’s treatment options. Next, the internist can provide advice when a treatment choice is

to be made, assist the patient and her family understand these options, and give other assistance.

Prior to surgery and immediately afterward, either the internist or the medical oncologist

manages any other coexisting conditions the patient may also have. They will also participate in

the discussions and impart important decisions regarding chemotherapy or postoperative

radiation treatment. Once the initial therapy is completed, a follow-up process is coordinated

among the internist and the breast management team. As necessary, the internist may have to

adjust or tailor his management of subsequent symptoms the patient is experiencing and use

other effective treatment options. The internist is frequently responsible for the patient’s long-

term follow-up exams, deciding which procedures may be needed, and appropriate examinations

to screen for signs of recurrent cancer.

A woman may be sensitive and emotional about her breast, including increasing concerns

about breast cancer, so the gynecologist must be sensitive to her concerns. The gynecologist

This Photo by Unknown Author is licensed under CC

BY-SA

Internist

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must also be aware of her reasons for procrastinating about initiating breast exams or when

finding a suspicious lump. With these reasons in mind, he or she should take responsibility for

teaching their patients the significance of performing breast self-inspection, its importance, and

techniques. In addition, they must monitor their patient’s performance to be sure that her

inspections are adequate. One reason for this is to assist the patient in gaining confidence in her

ability to successfully practice self-examinations. This specialized provider can assure her that

she will gain proficiency with her self-breast exams as she makes it a routine monthly practice.

THE BREAST MANAGEMENT TEAM

DIAGNOSIS, TREATMENT, AND REHABILITATION

Before a choice is made about the type of treatment, it is vital for patients to meet with

three of the team members from the breast cancer team. The three important providers include

the specialist, the radiation oncologist, and the medical oncologist. Together they will all come

up with the treatment plan that best fits each patient. They will discuss each option with the

patient. However, if the group believes a mastectomy is the best choice or if an oncoplastic

medical procedure is required, the patient will also see a plastic surgeon before definite treatment

proposals are established.

When all team members have examined the patient, the appropriate procedures have been

done, and test results are in - they will confer with one another, either by phone or a conference

in the same facility. They will then arrive at the treatment plan that best fits the patient’s specific

mental and clinical condition. Every patient’s treatment plan varies depending on the various

factors relating to their breast cancer. One option is perhaps a lumpectomy and sentinel lymph

node sampling or maybe a unilateral mastectomy with immediate reconstruction. Some patients

may choose to have chemotherapy followed by lumpectomy or mastectomy. Historically, the

theory of “one plan fits all” no longer exists in today’s medical breast cancer treatment plans.

Therefore, the specialized team approach is used to determine the best-individualized plan.

Within the last decades, several facilities have created clinics and cancer centers to

facilitate the team approach. Having all specialists working under the same roof provides for a

Recommendations to a Patient

• If her surgeon schedules her for definitive surgery before she has seen the radiation oncologist,

medical oncologist, and the plastic surgeon she should consult with another surgeon who is

more accustomed to working as a member of the team.

• If she is scheduled to begin radiation therapy before seeing the medical oncologist, she should

seek another radiation oncologist.

• If she is to start chemotherapy before seeing the surgeon and radiation oncologist, she should

consult with another medical oncologist. Figure 2.0 Berger, Bostwick, & Jones, 2011

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more efficient environment. This set up is convenient for the patient as she can meet with two,

and sometimes all three specialists of her team on the same appointment date. Seeing every

member of the team during one visit is not only convenient, but it also allows all procedures to

be immediately coordinated and scheduled. Second, the process is more efficient in that there

are fewer errors or redundancy of procedures, or risk of ordering incorrect laboratory studies,

imaging studies, and follow-up visits.

The following section will explain and study the roles played by different members of the

breast management team and how they interact with one another to provide optimum breast care.

The first to be presented will be the diagnostic radiologist, who fills a critical gap between the

patient’s primary care provider and all the other team members of the breast management team

working on treating her problem. Any of the patient’s providers may order either a screening or

diagnostic mammogram. However, a screening mammogram is ordered for asymptomatic

women, while a diagnostic mammogram is ordered when there is a diagnostic reason. Figure 3.0

illustrates several reasons providers may order a diagnostic mammogram, but there may be other

reasons as well. The radiologist will confer with the specialists and with the woman herself to

help screen for or diagnose any breast problems.

Detection and Diagnosis of Breast Disease: The Diagnostic Radiologist’s Role

A diagnostic radiologist is a physician with specialized training in interpreting x-rays or

digital imaging studies obtained via various machines, cameras, and other imaging equipment: x-

rays, mammograms, computed tomography scans, ultrasounds, and magnetic resonance imaging

scans (just to name a few). Some diagnostic radiologist specializing in breast imaging and are

Figure 3.0 Photo style by Unknown Author is licensed under CC BY-NC

Reasons for Diagnostic Mammogram

* Lump * Nipple discharge * skin thickening/dimpling

*xReddish or dark skin change * Pain * Follow-up from abnormal screening

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called breast imagers or breast specialists (Berger, et al. 2011). Many traditional radiologists

spend most of their time sitting in their office and reading imaging and interpreting images. Once

the diagnosis is determined, then the report is completed and sent to the attending provider for

their review. While other providers interact with their patients, radiologists usually do not

devote as much time interacting with patients, unless they practice interventional radiology.

However, radiologists still require interpersonal skills as many of their duties include

collaborating with team members when battling breast cancer and its detection. For example, the

radiologist is responsible for coordinating with the mammogram technologists and other imaging

professionals who obtain digital images, ultrasound, and MRI for breast detection.

Under most conditions, the diagnostic radiologist acts as a consultant to the patient’s

providers when they order imaging studies to be diagnosed and evaluated. In the case of breast

imaging, however, unlike other imaging tests, the radiologist assumes a more direct and

systematic role, speaking to the patient directly and discussing the results of her mammogram.

While the mammographer positions the patient for the actual images, the radiologist determines

the number and quality of images required, maintain a standard of quality control, and interprets

the examination itself. As previously mentioned, asymptomatic women will have a screening

mammogram in which case the radiologist typically does not interact with the patient.

If a screening mammogram comes back abnormal, and something is detected the

radiologist proceeds in evaluating the problem and takes the lead. Additional mammographic

views, sonograms, or MRI studies may be recommended by the radiologist to fully evaluate the

breast though that the radiologist can advise the referring provider as to whether an abnormality

exists and if perhaps it is likely to be either benign or malignant. The radiologist will also discuss

the results with the patient herself so that she may be aware of her breast condition and seek

further medical care and consultation with a cancer surgeon who deals with the breast problems.

Examples of Team Approach and Diagnostic Process

✓ Oncologist may order a diagnostic mammogram, ultrasound or MRI

of a patient to detect breast cancer

✓ A mammographer will perform the mammogram; Ultrasound

technologist will perform breast sonogram; MRI technologist will

perform MRI exam

✓ Radiologist will then interpret the information and put it in a report

for the oncologist

✓ Oncologists reviews the report to decide on the best course of

treatment

✓ The radiologist and oncologist consult if there is a question or further

clarification is needed

Figure 4.0

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While many female patients would prefer a female radiologist because of the sensitive issue with

their breasts, most radiologists are male. For example, only 27% of radiology residents in 2015

were female, and in 2016, almost 25% of the active radiologists were female (see Figure 5.0). It

is important for the radiologist to be sensitive to the patient’s fears and to take the necessary time

to explain what has been found on the mammogram and what that means for the patient.

Figure 5.0 Radiologist Copyright: Wikimedia Commons, Labeled for reuse. Statistics: Sources: Kaplan, 2015, Walter, 2018

If a patient or her physician locates a suspicious mass, lump, thickening, or other

abnormality in the breast, the patient should not be referred for a screening examination but

instead scheduled for a diagnostic mammogram. An abnormality may also be identified from a

screening mammogram. A diagnostic mammogram is performed by the mammographer under

the direct supervision of the diagnostic radiologist. At that time of the diagnostic procedure, the

routine mammographic four views will be taken, immediately followed by additional views

necessary to better evaluate the area of interest. Some radiologist will also conduct a clinical

breast examination on the patient to correlate the physical findings with the mammograms. Next,

the radiologist may recommend an ultrasound or MRI if warranted. After all the necessary

images have been taken, the radiologist offers their expert radiological opinion as to the type of

follow-up required. The radiologists consult with the patient’s provider, who in turn consults

with the other breast cancer management team members to determine whether careful

surveillance is needed or surgical consultation. Frequently the radiologist will confer directly

with the woman’s primary care physician to expedite a surgical consultation.

Another role the radiologists play is performing diagnostic procedures for the detection of

cancer, including breast cancer. When a suspicious abnormality can be seen on the mammogram

but cannot be felt, a biopsy is usually warranted. A procedure called breast needle localization in

which a small wire is inserted into the breast by the radiologist is performed. Using

mammography to ensure the accurate placement of the wire and then followed by a surgical

biopsy. This surgical biopsied tissue is then sent to a pathologist for cancer detection.

ACR 2015 Annual Meeting

46% of all medical students are women

27% of radiology residency programs

are female

-------------------------

AAMC – 2016 Report

24.7% active radiologists in the country

are female

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With the advancement of technology and invention of accurate equipment capable of

placing a needle within even the tiniest lesion that can be seen on a mammogram offers the

potential for a radiologist to perform less invasive biopsies of suspicious areas. Some of these

suspicious areas can only be seen using imaging guidance. Image-guided biopsies is done by a

radiologist who takes samples of a breast abnormality with the assistance and guidance from

mammograms, sonography, or MRI. A second exam performed by the radiologist is called a

stereotactic biopsy. Figure 6.0 provides common reasons why this procedure is done. This

procedure uses breast images to assists a radiologist in guiding a hollow needle into the patient’s

breast to collect a biopsy tissue. This procedure is less invasive but is not designed to extract the

entire breast lesion, instead only a small sample of the abnormality is collected for further study

(Guenin, 2019).

SSS In addition to detecting and diagnosing breast cancer, as a team member, the

radiologist plays other key roles in breast cancer detection. This specialist not only interprets the

breast images and consults with the women, but they also educate the patient about issues

relating to their procedures, results, and answers questions about breast-related concerns. Next,

they offer solace, comfort, and reassurance when necessary.

Detection and Diagnosis of Breast Disease: The Mammographer’s Role

The widespread availability and the broad use of screening mammography have resulted

in reducing breast cancer mortality rates by 40% for women (DeSantis, 2017). Mammograms for

screening purposes have been an effective tool for an earlier diagnosis of breast cancer.

Unfortunately, not all types of cancers are detected by mammograms. This diagnostic procedure

involves technical challenges including, some limitations with clinical application. For example,

women with implants, dense breast tissue, or diseases of the breast, such as severe dysplastic

offer technical challenges for mammography. In addition, women who have had breast radiation

therapy or breast surgery may have architectural distortion, which is challenging to visualize and

Common Reasons for Stereotactic

Biopsy

• A suspicious lump or mass

• Microcalcifications, tiny cluster of small calcium deposits

• A distortion in the structure of the breast tissue

• An area of abnormal tissue change

• A new mass or area of calcium deposits in a previous surgery site.

Figure 6.0 Source: Guenin, 2019

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interpret mammographically. As a result, the role of the mammographer, who is also a certified

radiology technologist, is taxing.

For screening and diagnostic purposes, a mammographer takes imaging x-rays of the

breasts. Mammographers require an advanced certificate specializing in mammography. The

rationale is to give the patient the best service, provide safety and quality of care. This

mammographic certificate provides higher employment possibilities in areas where specialized

training is in high demand. Plus, certification is required by certain governmental agencies and

organizations. The mammographer plays many roles in performing her duties.

As the patient arrives for her exam, the mammographer first do a brief interview and

completes a patient intake form. The mammographer informs the patient of the risks and benefits

of mammography to make sure that she understands the reason for the exam. It is important for

the technologist to ensure that the patient is not pregnant. Once the patient is entirely informed,

the mammographer will begin the exam. With extreme care and sensitivity, the mammographer

positions the patient in the mammographic machine in order to obtain an image of each breast.

This process requires extensive training, knowledge, and practice as each patient and their

breasts are slightly different. Errors in positioning may result in missing: anatomy, early signs of

breast cancer, or a cancerous area. Consequently, errors must be held to a minimum for the

safety of the patient.

Using a low-dose radiation mammographic machine, the mammographer performs the

images of the breasts by applying radiologic precautions to ensure the patient is protected from

high levels of radiation (see Figure 7.0). Next, it is the mammographers duty to ensure that all

staff in the immediate vicinity are also protected from high levels of radiation exposure. Upon

completion of the procedure and obtaining all the necessary images, the mammographer checks

the images, which must be clear, anatomically correct, and meet quality standards. If an

unacceptable image is found, the mammographer will retake that image immediately instead of

calling the patient back for repeat views. Once the technologist ascertains that all the images are

acceptable, she will release the patient if the exam is a screening mammogram. However, with

diagnostic mammograms, the patient is detained until the mammographer verifies the images

with the radiologist. At this point, the radiologist may request additional images for clarification

of an area of interest.

Mammogram. Copyright: Creative Commons, CCO

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An important role of the mammographer is to perform a mammogram in a professional

and competent manner. Consequently, it is essential that the mammographer has specialized

training in this area that will allow her to provide expertise and high quality of mammographic

care. One method in which this is accomplished is by the technologist obtaining continuing

education units that will keep her skills current. In addition, it is also important for the

technologist to be aware of new advances in technologies and procedures that advance the

detection of breast cancer. As part of her extensive training, the mammographer must be skilled

and experienced with several breast cancer detection techniques. Several of these were

previously mentioned (image-guided and stereotactic), but nonetheless, there are several other

procedures. For example, biopsies of sentinel lymph nodes have been reported as offering a safe

and sensitive method to predict metastasis of the axillary. Consequently, sentinel node injections

have advanced and play a major role in the mammographer's duties and are fundamental in many

specialized breast centers (Kelly, Kelly, and Kopman, 2008). This is only one example of a

specialized procedure for the detection of breast cancer; others are not presented as they are

outside the scope of this course.

Over the last two or three decades, many healthcare facilities have experienced financial

challenges which have resulted in their closing. This trend has also impacted the radiology and

mammography departments and centers. Consequently, the mammographer plays a vital role in

meeting financial constraints and providing services that are efficient and cost-effective. This

implies that providing services that meet this criterion is essential to the mammography

department. In other words, many facilities have a specific number of procedures, both

screening, and diagnostic that must be performed daily in order to be cost-effective.

Consequently, the role of the mammographer is to perform the mammograms in an efficient

manner, while meeting safety and quality criteria, in addition to meeting the per day quota.

A mammographer plays a vital role in infection control and the spread of infections,

which may jeopardize the patient’s health and safety. Infection control is of utmost importance,

as patients and staff must be sufficiently protected from the risks related to providing or

receiving medical care. Mammographers receive infection control education, training in

procedures that prevent infection and ensure they follow the appropriate policies. Consequently,

the mammographer’s role is to ensure that the equipment and mammogram process is infection-

free by taking the correct measures and limiting the spread of germs.

As previously stated, using mammography screening is directly related to decreased

mortality due to early breast cancer detection. Another role for the mammographer is to act as

outreach agents and encourage patients to engage in routine screening. They can inform and

educate the patient as to the importance of annual breast screening and dispel any myths or

misconceptions. In addition, as professional healthcare employees, mammographers are well

placed to address the patient’s knowledge, psychological, and cultural barriers to annual

screening. Unfortunately, mammographers have few opportunities to acquire the necessary skills

to provide cultural-sensitive patient education, emotional or psychological assessment needed to

assist female patients in overcoming these challenges and barriers.

17

Mammograms are performed in various settings such as hospitals, community or

specialized clinics, public health departments, and mobile units. Mammograms performed via

mobile breast units are employed throughout the US to provide access to many women who do

not have easy access to early breast cancer detection exams. These units also provide an

excellent opportunity for mammographers in mobile units to provide education and outreach to

low-income patients.

Detection and Diagnosis of Breast Disease: Ultrasound’s Role

Ultrasound imaging also referred to as sonography, is a specialty modality that assists the

providers in evaluating, diagnosing, and treating medical conditions. Unlike radiologic imaging,

sonography does not use ionizing radiation exposure. Ultrasound incorporates high-frequency

sound waves to view the internal body. Ultrasound images are taken in real-time as they illustrate

blood flowing through the blood vessels and movement of the internal organs.

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18

With ultrasound procedures, a hand-held transducer is placed directly on the skin or

inside a body opening. Just before beginning the procedure, a small amount of gel is applied to

the skin so that the sonographic waves are transmitted from the probe through the gel into the

body. Accordingly, the ultrasound image is created based on the sound waves reflecting off the

body structures. The information needed to make an image is created from the strength of the

sound wave and the time it takes for the wave to travel through the body. In addition to breast

ultrasound, the sonographer will perform other types of ultrasound procedures (see Figure 7.0).

An ultrasound technician, also known as a sonographer, does more than just operate the

ultrasound machine. They work cohesively with the breast cancer detection team while balancing

completing exams, technological performance, and patient interaction. Like mammographers,

ultrasound technicians are also employed in clinics, hospitals, private offices, and outpatient care

facilities. However, they may also be employed at universities and other healthcare sites.

Another role the ultrasound technician does is to communicate with the patient and

ensure that the patient understands the procedure being done, and answer questions the patient

may have. Once the images are obtained, the ultrasound technician evaluates their images for

accuracy, completeness, and quality. Next, they will present the images and their worksheets to

the radiologist for their interpretation. The radiologist has the ultimate responsibility for the

interpretation and report of the ultrasound images. Consequently, the radiologist may request

additional images, which means the ultrasound technician will have to return to the exam room

and perform the requested images. Last, the ultrasound technician is responsible for adding

medical notes related to the ultrasound procedure and maintaining patient records.

Common Ultrasound Imaging Procedures

• Abdominal ultrasound (to visualize abdominal

tissues and organs)

• Breast ultrasound (to visualize breast tissue)

• Fetal ultrasound

• Doppler ultrasound

• Doppler fetal heart rate monitors

• (to visualize blood flow through a blood

vessel, organs, or other structures)

• Bone Sonometric

• Echocardiogram (to view the heart)

• Ultrasound-guided biopsies

• Ophthalmic ultrasound (to visualize ocular

structures

• Ultrasound-guided needle placement

Figure 7.0 Source: FDA.gov, 2019

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Detection and Diagnosis of Breast Disease: MRI’s Role

MRI technologists play a significant role in providing procedures for breast cancer

detection. Between 2010 and 2020, the Bureau of Labor Statistics expects an increase of 28%

growth in demand for MRI technologists (Decker, 2019). One reason for this increase is the use

of MRI procedures to support the detection of cancer, including breast cancer. A MRI scanner

uses strong magnetic fields and radio frequencies needed for creating 3D images of the internal

organs and tissues. Unlike x-rays, CT scans, or PET scans, MRI scans do not use ionizing

radiation. These scans are needed by providers to determine specific types of diagnoses. Trained

MRI technologists provide radiologists with the magnetic resonance images they need for

interpretation. MRI technologists may first begin as certified radiographers and specialize in

MRI later, or they may attend a specialized training academy or program.

One role for the MRI technologist is communication as they work directly with the

patient and prepare them for the exam. They must first explain the procedure to the patient in a

composed and comforting manner. Plus, it is important for the MRI technologist is to respond

with compassion to expressions of fear or claustrophobia. Next, the technologist will ensure that

no jewelry, piercings, hearing aids, and pacemakers are worn by the patient while in the MRI

scanner as they may cause injury from the machine's strong magnetic field. Part of

communication is their ability to read and comprehend the written instructions by providers and

the radiologists to perform the appropriate procedure and images for the affected area of the

patient's body.

The MRI technologist’s second role in breast cancer detection is positioning the patient

within the MRI machine. Often some procedures require sedation; this is especially true with

pediatric patients. Like mammographers and ultrasound technologists, the MRI technologist may

have to repeat images if the initial images are not of high enough quality, or perhaps correct

anatomy is not properly imaged. A vital role of the MRI technologist is to have a high level of

skills for this specialized field. For example, many technologists specialize in neurological brain

scans, which requires an in-depth understanding of human anatomy, and the capability to

recognize irregularities and abnormalities.

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Detection and Diagnosis of Breast Disease: Radiation Therapy’s Role

When a female patient has been diagnosed with breast cancer, her team providers may

decide that radiation therapy is required. The basic role of the radiation therapist is to treat

other diseases and cancers, including breast cancer. They must be licensed in their state, but

requirements vary from state to state. Radiation therapy is done by administering radiation

treatments to patients and consists of radiation therapy machines called linear accelerators. The

radiation therapy machine works as it targets high-energy x-rays at precise cancer cells in a

patient's body. This results in shrinking or removing the cancerous tumor.

Like the previous technologists, the radiation therapist must possess vast

communication and interpersonal skills to provide instructions to patients. They work directly

with patients, so it is crucial that therapists be relaxed when interacting with their patients who

may be going through emotional and mental stress. Being detail-oriented is a vital skill

radiation therapist need to input exact measurements for radiation therapy. It is essential to

make sure the patient is exposed only to the amount of radiation needed for therapy. Another

role for radiation therapists is to provide technical expertise while applying radiation therapy,

using high-tech computers and large pieces of technological equipment. Their expertise

included knowledge of the human body and anatomy, physiology, and physics. Radiation

therapists play an important role as part of the oncology team that treats a breast cancer patient.

As part of the breast detection team, they have many duties (see Figure 8.0).

Radiation therapist’s duties include:

• Explains plan of treatment to patient and answer questions

• Operate the machine to treat the patient with radiation

• Follows radiation safety procedures

• Image the patient to determine the exact location of the area requiring treatment

• Monitor the patient – for reactions

• Quality Control on machines

• Maintain detailed records of treatment

Figure 8.0. Source: Truity.com, 2019

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Additional Imaging Technologists and roles

In addition to the imaging technologists presented above, there are other imaging

technologists that play a role in breast cancer detection. For example, a certified radiology

technologist may have to perform a pre-op chest x-ray on a breast cancer patient who will be

going to surgery. In addition, a patient’s provider may suspect metastasize and want a CT or PET

scan.

Additional roles for the ultrasound, MRI, and radiation therapists are like those presented

in the mammographer section. These include communication with the patients, infection control,

and acting as an outreach agent. Plus, they are also expected to provide education about their

specific expertise. Last, patients diagnosed with breast cancer are under a lot of stress and

emotional pressure, which means these professionals must provide emotional support and

comfort.

The Surgeon’s Role in a Woman’s Breast Care

Breast surgeons are experts in diseases of the breast, and this aspect of patient care

represents an important part of many surgical practices. The cancer surgeon is usually the one

who is consulted when a female patient or her primary care provider finds a suspicious lump or

mass. After examining the patient and reviewing her mammograms, it is the surgeon who will

ultimately decide whether to recommend a breast biopsy. In arriving at this decision, the

patient’s history, risk factors, and mammograms are collected. In general, one of three conditions

will result in a recommendation for breast biopsy:

• A dominant lump

• A suspicious or indeterminate mammogram

• Bloody nipple discharge

Often the results of a mammogram will suggest a biopsy, even when a palpable lump or

mass cannot be felt. In those cases, as previously discussed, a stereotactic needle biopsy or a

needle localized excisional biopsy is requested rather than a surgical biopsy. The surgeon has the

ultimate decision and discusses the options with the patient and the other breast cancer detection

team. The surgeon will make recommendations as to which is the most appropriate option for the

patient’s case. Surgeons often can place an ordinary hypodermic needle into the lump if it is

palpable. This is a minimally invasive procedure, but the surgeon gains valuable information

fast and with minimal distress.

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The surgeon plays a key role when a female patient is diagnosed with breast cancer. The

surgeon must be able to sympathetically discuss with the patient, her family, or caregivers the

many options surrounding her breast cancer condition. It is important for the surgeon to appoint

enough time to help the patient sort through the plethora of information. Customarily, the

surgeon explains that there are two essential issues to be dealt with, when breast cancer is

detected: controlling cancer within the breast and controlling cancer from metastasizing to the

rest of the body. A patient is given many choices in these areas, and it is important for the

surgeon to adequately discuss these options with the patient. It is also imperative that the patient

feel comfortable and relaxed with her surgeon so that she is unafraid to ask basic questions.

For the patient who needs a biopsy, the role of the surgeon is not only to perform the

biopsy, but also to provide the information, emotional support she requires and ensures the

consent forms are completed. What this means is that he explains the reason for the biopsy and

the issues involved in the surgery. It is essential for the patient to comprehend when the final

pathology report of the surgery will be available and can be discussed with her surgeon.

Another role of the surgeon is to act as a resource for the patient, being knowledgeable

about the various issues of breast cancer, treatment, and prognosis. Today, patients are kept

informed by social media and the internet but nonetheless expect their surgeon to answer their

questions. Many patients do not require a biopsy, but they do need an expert such as the surgeon

to provide them with data and information about their breast and breast cancer. The breast

surgeon uses their expertise to inform, educate, and reassure their patients about benign breast

conditions and breast cancer. Like the mammographer, the surgeon needs to reinforce the

importance of breast self-examination, clinical breast examination, and the necessity for

mammography annually.

After satisfying the role of the teacher in educating the patient, the surgeon will often act

as the coordinator of the breast cancer team. They will coordinate the other team members such

as a radiation oncologist, medical oncologist, genetic counselor, plastic surgeon, and support

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group personnel. The surgeon can make suitable recommendations for treatment and then

skillfully carry out the agreed-upon surgical plan, whether mastectomy, lumpectomy, or breast-

conserving surgery. Figure 9.0 provides questions a patient facing breast cancer may ask her

surgeon. Figure 10.0 provides questions a patient may ask if a biopsy is needed.

Questions a patient might ask her surgeon

How should I examine myself?

What time of the month is best?

How often and when should I see my doctor?

What are my risks of breast cancer?

What can I do to lessen my risks?

When is genetic testing indicated to determine whether I

carry a breast cancer gene?

Is mammography necessary?

Should I undergo additional imaging tests, such as

ultrasound or MRI

Figure 9.0

Questions a patient may ask if a biopsy is necessary

❖ Is a biopsy necessary? Will they take the whole lump, or just

partial?

❖ When will the results be available?

❖ If it is cancer, what are my treatment options? Can you explain the

risks or benefits for each option?

❖ Will I lose my breast? If so, may I have breast reconstruction?

❖ Can I have a fine-needle aspiration or a minimally invasive biopsy

procedure?

❖ Can the biopsy be done as an outpatient or inpatient?

❖ Will I be put under general or local anesthesia?

❖ If I have a surgical biopsy, what will the scar be like?

❖ After biopsy, how long do I have to make up my mind for treatment

if the biopsy reveals cancer?

❖ What are the differences between breast-conserving surgery and

mastectomy? Which one is safer?

❖ Will I need radiation therapy, chemotherapy, or hormonal therapy?

❖ What are the anesthetic ramifications of treatment? Figure 10.0

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The Pathologist’s Role in the Diagnosis and Treatment of Breast Problems

Another specialist in the breast cancer detection team is the pathologist, who plays an

important role as a specialized doctor in the analyzing, diagnosis, and reporting diseases in the

laboratory. They look at and analyze tissues attained from biopsies or removal of organs and

analyze blood and other body fluids. They are experts in cytology (analysis of cells from tissue

and fluids) and analyze PAP ‘s smears. With regards to breast tissues, they analyze secretions

from the nipple, identify malignant cells, and fine-needle aspirates from breast masses. It is vital

that the pathologist be completely familiar with the microscopic anatomy of the breast. Next,

they must be experts to diagnose and identify breast cancer, and the various disease states that

affect it. While the pathologist plays an important role in the patient’s life as he/she is the one to

positively diagnose her condition as breast cancer, but it is not likely that she will meet the

pathologist.

Usually, the specimen biopsy tissue that the surgeon removes and sends to the pathology

department, where the pathologist analyzes it considering the surgeon’s findings, which are

written on a requisition sheet that accompanies the specimen.

In order to confirm the specimen belongs to the patient, her name, date of birth, date of

service, and medical record is confirmed by the pathologist. The next step is to analyze the

specimen. Next, the pathologist determines if there is cancer, if so what type - whether the cancer

is intraductal (in situ) or invasive (infiltrating). If the sentinel node or axillary node dissection

has been biopsied, the pathologist microscopically examines the lymph nodes to determine the

presence carcinoma. Also, the pathologist performs many tests to identify specific oncogenes

(i.e., HER-2/neu).

Unlike the other members of the breast cancer detection team, the pathologist has no

communication with the patient. However, they work with other members, so having high

communication skills is still a necessary skill. On the other hand, they do need excellent writing

skills since the final report issued by the pathologist diagnoses cancer, classifies it based on the

various findings. This report is used by the surgeon and other members of the breast management

team and planning her treatment plan.

Copyright: Public Domain

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The Role of the Genetic Counselor

One specialist that is somewhat new to the breast cancer detection team is the genetic

counselor, who is a healthcare provider specializing in clinical genetics and family-based risk.

They have training in general clinical and molecular genetics. The role of the cancer genetic

counselor is to educate patients about their family-based cancer risk, manage appropriate medical

screening, and interpret genetic testing. Plus, genetic counselors are trained to recognize and

acknowledge the psychosocial complexity of the inherited disease, including cancer. They also

inform and educate the patients regarding their significant breast cancer risk factors (see Figure

11.0).

Evaluation of the first two risk factors is straightforward; evaluation of the family cancer

history is often challenging. The reason for identifying the patients with increased breast cancer

risk is to institute medical recommendations that appropriately reduces this risk. As the genetic

counselor has direct interaction with the patient, they need to have positive communication

skills. Their role entails supporting and comforting patients when diagnosed with breast cancer.

Female patients are typically referred for genetic counseling for different reasons (see Figure

12.0). The genetic counselor must collect data and other demographics from the patient (see

Figure 13.0).

Breast Cancer Risk Factors

❖ Sex

❖ Age

❖ Family history

Which women get referred for genetic counseling

▪ Women diagnosed at a young age (less than 45 years old)

▪ Women who have a family history suggestive of hereditary cancer

▪ Women diagnosed with two separate primary cancers, bilateral

breast cancer, or breast cancer and another type of cancer

▪ Women with a family history of a male relative with breast cancer

▪ Women with a known family history of cancer gene mutation or

genetic condition

▪ Women with specific questions about their family history of cancer

Figure 12.0 Source: Berger, Bostwick, & Jones, 2011

Figure 11.0

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The Radiation Oncologist’s Role in Treating Breast Cancer Patients

A specialized doctor who works in evaluating, diagnosing, and treating cancer patients is

called an oncologist. The patient’s oncologist manages their care and treatment from the

beginning of diagnosis throughout the treatment course of the disease. It is common for a patient

with breast cancer is often treated by a team of oncologists who are experts in different areas of

oncology care. Not many people are aware that there are different types of oncologists.

Oncology, the study of cancer, has three key areas: medical, surgical, and radiation (see Figure

14.0).

History Data to be collected

• List all family members, including children,

siblings, parents, grandparents, hands, uncle, and

cousins. Include paternal and maternal family

members

• Indicate the type of cancer and the stage at which

person was diagnosed with cancer

• Indicate with organ or site where the cancer began.

Note if it metastasized

• Include family members with any type of cancer,

including tumors that develop during childhood

• Collect death certificates or medical records is

useful in clarifying a family member specific cancer

• Document the race/ethnic background

Figure 13.0. Source: Berger,

Bostwick, and Jones, 2011

3 Key Areas of Oncology

• A radiation oncologist manages and treats cancer using radiation therapy

• A medical oncologist manages and treats cancer using medication, targeted

therapy, immunotherapy, or chemotherapy

• A surgical oncologist performs certain types of biopsies for breast cancer

diagnosis, and removes cancerous tumor and nearby tissue during surgery

Other types of oncologists

• A gynecologic oncologist manages and treats gynecologic cancers

• A pediatric oncologist manages and treats cancer in children

Figure 14.0 Sources: Cancer.net, 2018

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The radiation oncologist is a crucial member of the breast-cancer management team and

plays a vital role in the patient’s treatment. Before any decisions regarding treatment are made, it

is essential for the patient to be examined in consultation by all three team members: the

radiation oncologist, medical oncologist, and the surgeon.

The radiation oncologist’s role is to ensure that the patient gets the best treatment plan

that is individualized to her situation. His special expertise is in the use of ionizing radiation - a

potent killer of malignant cells. The radiation oncologist’s role is to determine when and whether

radiation can be used but includes the other members of the team: surgery, radiation, and

chemotherapy. The radiation oncologist also decides on how much and what type of radiation

therapy should be used and what anatomical areas should receive radiation. Another of his/her

responsibilities is to deliver the radiation dose effectively, timely, and safely.

Education and training play a vital role in the radiation oncologist’s treatment of the

patient. They must have a broad range of training and a complete understanding of all types of

cancers. He should be knowledgeable in nuclear physics, physics of ionizing radiation, and the

newest techniques for giving the right amount of radiation to cancerous tissue while sparing

normal tissue. This specialist must also know the effects of combining chemotherapy and

radiation. In addition, he/she must be skillful and knowledgeable about general medicine while

managing the patient’s other medical conditions. Last, having the knowledge to refer the patient

to other physicians when medical symptoms arise outside his/her area of expertise. The radiation

oncologist has several different duties:

• the initial consultation

• performed a physical examination order

• evaluate all appropriate x-ray studies and blood tests,

• reviews the biopsy specimen with the pathologist.

• he confers with the surgeon and medical oncologist

• as a team they all determine whether radiation is indicated

The radiation oncologist also treats the patient during and after the completion of

radiation therapy. He oversees the daily radiation treatments given to the patient to follow his

plan and monitors the effects of the radiation. Next, he must recognize which symptoms are side

effects of the radiation treatment and manages all side effects and problems effectively. Once

this treatment has been completed, the radiation oncologist assesses the effectiveness of the

treatment and monitors the patient regularly to assess for radiation complications and growth of

cancer, and/or the development of new cancers.

Follow-up visits for the patient must be coordinated among the team members. The team

approach can also be used for the follow-up of breast cancer patients. So that the patient is not

seen by different members of the team within a short period. Another role of the radiation

oncologist is to provide ongoing emotional support for the patient and her family. It is very

important to the patient that the radiation oncologist sincerely cares for her well-being. Second,

he must be willing to answer all her questions and to help with any issues that may arise.

Characteristics for the radiation oncologist, include sincerity, compassion, patience, and

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sensitivity. Many female patients diagnosed with breast cancer will be emotionally and

psychologically unsettled, sot the radiation oncologist must be supportive to her emotions and

needs.

Of equal importance is the ability to communicate and educate effectively. Patient

education is one of the radiation oncologists most important roles. According to Berger,

Bostwick, and Jones (2011), it is crucial that the radiation oncologist provide clear and easily

understandable answers to the following questions:

• What kind of cancer do I have, and how does it grow and spread?

• What are my treatment options, and how successful it needs option? If more than one

treatment is used, why? How are the different treatments combined?

• What is the specific purpose of each of the treatments?

• What are the potential side effects and complications of each of the proposed treatments,

and what are the chances of these occurring?

• What are the consequences of the complications if they occur, and what is the treatment

for the complications?

• Will I be able to engage in normal daily activities during the treatment? If not, what are

the restrictions, and how soon can normal activity be resumed?

• Are there any alternatives to proposed treatment, and what are the chances of success and

possible side effects of these alternatives?

These questions are only a few that must be explained clearly and simply to the patient.

In addition, the patient should be allowed enough time to ask further questions after she has had

time to reflect. The radiation oncologist must also make every effort to ensure that the patient

fully understands what is said. This is the role of the medical interpreter (presented later in this

course). A helpful suggestion is for the radiation oncologist to explain and give answers to

questions at least twice. Most patients will not fully comprehend all the facts and concepts on

the first explanation, particularly since she is not familiar with the medical terms. Being in a

state of shock, emotional upheaval, and extreme anxiety from recently being diagnosed with

breast cancer impacts her level of understanding. Another helpful suggestion is to have a friend

or other family member with the patient present when explanations are provided.

Unfortunately, not many providers can have great interpersonal skills and communication

skills. In addition, many physicians do not take the time or make any effort in developing these

skills. This is unfortunate because being able to help the patient understand all aspects of her

disease and treatment will greatly diminish her fear. Being able to explain the medical facts and

concepts in simplified terms is an important role.

Patient education is one of the most important responsibilities of any provider or team

member, not just the radiation oncologist. In summary, a good radiation oncologist must be

knowledgeable and skilled in all aspects or radiation therapy and be compassionate, sincere, and

supportive of the patient’s emotions and fears. Next, they must also have excellent

communication skills, be a great educator, as well as an effective team player.

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The Medical Oncologist’s Role in Treating a Woman with Breast Cancer

The medical oncologist is board-certified in medical oncology, a doctor who has special

training in cancer therapy. The role of these doctors is to manage the multidisciplinary care of

patients with breast cancer. Either the primary care provider or the surgeon will refer the patient

to the medical oncologist once the diagnosis of breast cancer has been established. The medical

oncologist joins the breast cancer detection team before definitive surgery has been performed so

that his input can be included in the treatment plan. For example, he will advise the team as to

what additional studies are needed to determine appropriate systemic treatment and therapy.

When a metastatic disease is involved, the medical oncologist usually plays a significant role in

using systemic therapy as the foundation for the patient’s treatment.

One type of treatment medical oncologists use is called systemic therapy, which refers to

treatment via the bloodstream into all parts of the human body to destroy cancer cells. There are

several types of systemic therapy, including hormonal, chemotherapy, or targeted therapies.

Targeted therapies are the newest type of treatment used in the oncology field. The oncologic

medicinal agent may be given by vein, mouth, or injection into the skin or muscle. The medical

oncologist role is to:

▪ Collects patient information needed for decision making systemic therapy

▪ Supervises the administration of the systemic therapy

▪ Monitors patient’s response to treatment (therapy)

▪ Manages the patient closely during systemic therapy

▪ Evaluates the patient for side effects and alters the treatment regimen

Today, the National Comprehensive Cancer Center Network (NCCN) has established

guidelines to assist in selecting the appropriate diagnostic tests and treatments for the various

stages of different cancers, including breast cancer (Berger, Bostwick, & Jones, 2011). It is

essential that the medical oncologist be knowledgeable and skillful in the newest developments

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in breast cancer therapy. Following the NCCN guidelines is crucial in order to provide

standardized care and treatment for patients and to properly integrate them into the patient’s

breast cancer regimen. The medical oncologist has special training to handle complications of

cancer and its treatment. Currently, once the systemic therapy has been completed, the role of the

medical oncologist is experiencing a change in managing and treating a breast cancer patient.

One reason for the change is due largely to financial constraints.

Society can no longer afford to have all providers such as the surgeon, medical

oncologist, and radiation oncologist all treating the patient simultaneously once the patient is

deemed cancer-free. Follow-up visits can be costly if all three doctors are seeing the patient

every three months. Testing for disease recurrence can be done efficiently and coordinated cost-

effectively among the breast cancer team. A patient needs to comprehend the reasons why she is

seeing an oncologist. Questions about the stage of her disease and the implications it has for her

life or prognosis should be addressed by the medical oncologist. Some of the questions that she

might ask with anticipated answers included the following:

It is crucial that the breast cancer patient understand the benefits and potential health

effects of treatment. A critical issue with chemotherapy is the side effects the patient may

experience, so these must be clearly outlined. In addition, explaining strategies of prevention and

how to minimize the toxicities is also relevant.

This Photo by Unknown Author is licensed under CC BY-NC-ND

Questions Patient might ask the Medical Oncologist?

❖ Why are drugs used to treat cancer?

❖ Why are there side effects of chemotherapy

❖ What are the most important side effects?

❖ Why does my blood cell count have to be checked every

time I go for Chemotherapy?

❖ What can be done to prevent side effects of chemotherapy?

❖ Are there other generalized effects of which the patient

needs to be aware

❖ What should I expect from cancer treatments?

❖ How do you know which drugs to use? Figure 15.0

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Treating a Breast Cancer Patient: The Oncologist Nurse Practitioner’s Role

The oncology nurse practitioner may dedicate their time solely to areas such as

hematology, pediatric oncology, or even breast cancer. They work with patients in hospitals,

clinics, and private homes while administering care for cancer patients. The main role of the

oncology nurse practitioner is to treat patients with cancer by overseeing and giving

chemotherapy. This can be accomplished by using new techniques with the advancement of

technology, observing patient’s improvements, and caring for cancer patients. An oncology

nurse practitioner must be prepared and agreeable to work with women who have terminal or

life-threatening breast cancer.

Commonly, under the supervision of an oncologist, an oncology nurse practitioner’s role

includes assisting with diagnosis, consultations, and therapy. In addition, they provide follow-up

care for breast cancer patients. As an oncology nurse practitioner, they work with several other

professional areas and departments, including radiology departments. Consequently, they should

have outstanding skills in communication, interpersonal skills, and have excellent medical

terminologies knowledge. Another of their role is to assist the patient and patient’s family

members with making informed choices and decisions. Next, the oncology nurse practitioner is

supposed to show the characteristics of patience, comprehension, poise, and compassion when

treating cancer patients and their families. Last, they need to have strong emotional stability to

support patients and their families so the patient can tolerate the treatment procedures, handle

hospice, and death situation when applicable. Figure 16.0 illustrates other duties for the

oncology nurse practitioner.

Oncology Nurse Practitioner Role

• Giving physical examinations and evaluating a person’s health

• Diagnosing and treating certain conditions

• Recommending diagnostic and laboratory tests, and reading the results

• Prescribing medications and giving chemotherapy

• Managing cancer and treatment side effects

• Record observations and progress

• Educating and counseling people about cancer

• Performing certain procedures

• Performing research as part of a clinical trial

Figure 16.0. Source: Cancer.net, 2018

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Caring for Breast Cancer Patients: The Oncologist Nursing Role

The oncology nurse’s main role as a healthcare professional and registered nurse is to

provide ideal nursing care to patients who have been given a diagnosis of breast cancer. Many

oncology nurses are certified in oncology nursing (OCN). This is important because the level of

knowledge must be high enough to perform the tasks necessary for competent practice when

treating breast cancer patients. Normally, the oncology nurse must provide regular nursing care

before branching out into another field such as oncology. A patient with breast cancer may

encounter an oncology nurse that has experience from many different specialty areas, including

breast cancer.

As seen in Figure 17.0, one of the oncology nurse’s role is to coordinate the patient’s care

with all the oncology team members. However, she/he may also have responsibilities

coordinating care with other departments such as the mammography department. For example,

the mammographer may receive a call from the oncology nurse regarding a question or concern

about the results, clarifying an issue about a patient’s procedure and exam, or requesting the

patient’s mammograms.

The oncology nurse must have extensive knowledge of breast cancer, treatment

strategies, side effects of treatment, and a complete understanding of the plan of care for each

breast cancer patient. Other than the clerical assistance, the oncology nurse is the patient’s first

contact when she arrives at the surgeon’s office for a consultation for a breast lump or a breast

biopsy. Consequently, like the previous team members, the oncology nurse must be able to

support feelings and to alleviate the anxiety the patient is feeling.

Duties of Oncology Nurse

• Performing physical examination

• Administer medications and

chemotherapy

• Assess and identify patient needs

• Coordinating care with oncology

team members

• Performing research as part of a

clinical trial

• Counsel and educate patients, other

caregivers, and family

Figure 17.0 Source: Cancer, net, 2018

•

33

The oncology nurse plays a vital role when the medical oncologist receives a referral for

chemotherapy or hormonal therapy as a form of treatment. For example, chemotherapy will be

given by the oncology nurse who has been specifically trained to give chemotherapy drugs

appropriately. The treatment may be given in a variety of settings such as the oncology facility,

ambulatory care facility, hospital, patient’s home, or the provider’s office. An additional role for

the oncology nurse is to monitor toxicity levels and to recommend adjustments in the patient’s

treatment schedule.

Another role for the oncology nurse is to communicate with their patients as they instruct

the patient in the care of the biopsy site or assist in coordinating additional tests such as

mammography, ultrasonography, or surgery. The oncology nurse may have to speak to the

patient regarding:

✓ surgical options

✓ expected recovery period

✓ pathology reports

✓ surgical summaries

✓ x-rays, laboratory, and other reports

Like the medical oncologist, the oncology nurse will provide in-depth explanations of

drug therapy, answer the patient’s questions and concerns regarding expected side effects,

treatment, and anticipated lifestyle changes. Post-surgery, the patient may need assistance with

dressing, drainage care, or other post-operative care, in which case the oncology nurse can be of

some assistance. Also, some types of chemotherapy treatment may be given at home instead of

in an outpatient facility or hospital – again, the assistance of the oncology nurse is vital.

Consequently, educating the patient, family members, and other care providers on the basics of

self-care ensures that the correct healthcare can be carefully given in the home. Education is a

major role of oncology nurses in all specialty areas. In addition to the details of a specific

treatment of breast cancer, the oncology nurse will make recommendations for follow-up care,

physician examinations and breast examinations, as well as early detection methods, such as

mammograms for the patient.

In addition to providing hands-on care to these patients, the oncology nurse’s role as a

liaison between the physician and the patient with breast cancer, and between the patient and

other departments. Female patients will rely extensively on their nurses for resources, ideas,

express their worries, hopes, and fears, as well as state their anger and grief. The nurse has the

unique opportunity to become the breast cancer patient’s confidant because of the predominance

of females as nurses and males as physicians, a natural female bonding between the patient and

nurse frequently evolves. The various roles of the oncology nurse are especially rewarding ones,

which enables the nurse to establish long and like-long bonds with breast cancer patients. This

special bond helps these patients cope with their breast cancer and the challenges impacting their

lives. Research shows that “these women share with oncology nurses their joys and hopes, their

idiosyncrasies, their family pictures and stories, and their tears of sadness as well as their tears of

joy,” (Berger, Bostwick, and Jones, 2011).

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Rehabilitation of a Patient with Breast Cancer: The Plastic Surgeon’s Role

Patients seek the assistance of plastic surgeons for aesthetic breast operations to enlarge,

reduce, or alleviate their breasts. However, as a physician and a team member, the plastic

surgeon’s key role is to treat breast cancer patients with a wide range of issues and deformities.

They perform aesthetic surgical procedures to offset the effects and deformities resulting from

breast cancer treatment. A major component of a plastic surgeon’s practice is in performing

breast surgery, and their services are in high demand.

Plastic surgeons have become an increasingly important part of the breast cancer

treatment team. Their role is in reconstructive breast surgery for patients with breast cancer who

need to replace their missing breasts and nipples – after a mastectomy or reconstruct the defects

after breast-conserving surgery (Berger, Bostwick, and Jones, 2011). New and advanced

developments in surgical breast care, combined with the skills learned from treating aesthetic

breast conditions, allow plastic surgeons to design aesthetic breast reconstruction techniques.

These newer breast reconstruction techniques can be applied to breast cancer patients who have

undergone different types of mastectomy deformities, or also lumpectomies.

As previously mentioned, a patient should consult with the plastic surgeon before she

undergoes cancer surgery. Many times, this consultation occurs in a conference with the other

physicians on her breast cancer team, and when she is considering her options for local and

systemic therapy. The patient and her team of doctors will assess her options of reconstructive

breast surgery: to fix a defect, replace a missing breast, or correct an asymmetry area resulting

from a lumpectomy. Countless patients also come to the plastic surgeon after a referral by other

patients who have been treated by him for similar problems.

It is very important that the patient’s medical history, demographics, reports, and the

status of treatment for her breast cancer be obtained by the plastic surgeon so that he can

formulate a plan for breast reconstruction. However, his first step will be to perform a physical

examination to evaluate the options for reconstruction. The choices will then be discussed with

the patient, addressing each choice and topic, including the pros and cons, expected results, and

the risks of each approach. The discussions should include the anticipated length of hospital stay

and recovery periods. This is very important for many patients as they are employed and fear

losing their job. It is the plastic surgeon’s role to inform the patient and provide a complete

description of any devices, problems, or complications associated implants or expanders if the

patient chooses to have these as part of her breast reconstruction.

The plastic surgeon’s next role is to be compassionate, understanding, and be aware of

some of the challenges faced by the patient impacted by breast cancer and is seeking his/her

assistance in reconstructive breast surgery. Although a patient may need to have her breast

reconstructed, she may fear that reconstructive surgery may cause a reoccurrence of her cancer.

The plastic surgeon needs to be sensitive to this fear and address the patient’s fears accordingly.

The patient may also fear being deemed as vain in that this elective surgery will be misconstrued

as mere vanity. Consequently, the patient can be reassured by a plastic surgeon, as his/her role is

35

to reassure her that breast reconstruction is not a cosmetic stage, but a beneficial part of her total

rehabilitation program.

Today, female patients who wish to avoid permanent breast loss will choose to have

immediate breast reconstruction. It has become the ideal strategy to achieve the most aesthetic

reconstructive result. Women will get excellent aesthetic outcomes when they obtain immediate

reconstruction and combining skin-sparing mastectomy and oncoplastic techniques. When

immediate reconstruction is scheduled, the plastic surgeon will consult with the cancer surgeon

to coordinate the reconstructive procedures and mastectomy. These arrangements and facts must

be discussed at the initial consultation, with all the other physicians present.

One of the plastic surgeon’s role is to be a good listener as well as the educator. In other

words, the doctor should listen more instead of doing all the talking and allow the patient to talk

so that she can relay her expectations of the treatment as she understands them. The plastic

surgeon should ask the patient open-ended questions and understand what the patient wants and

expects so that they can plan accordingly. The surgery should meet the patient’s expectations,

and if the desired results cannot be met, he needs to explain the issues and limitations of what

surgery can or cannot accomplish.

Each patient that is scheduled for surgery is given an informed consent document that

comprehensively describes the advantages and disadvantages of the operation. The plastic

surgeon’s role is to ensure that the consent form is signed by the patient or their authorized care

provider. However, it is very crucial that the patient read the informed consent forms,

comprehend the information presented before signing them and agreeing to the operation. They

should ask the plastic surgeon questions if they are unsure of what the consent forms state.

Last, the actual breast reconstruction surgery is performed by the plastic surgeon

according to the preoperative plan that the breast cancer management team, the patient, and he

discussed, and agreed to. The precise procedure is listed on the consent form that the patient

signed. After reconstructive surgery, the patient may continue to see the plastic surgeon for

follow-up visits, in which the plastic surgeon continues to evaluate her rehabilitation from breast

cancer.

Counseling/Caring for Breast Reconstruction Patients: The Plastic Surgery Nurse’s Role

Like the previous nurses on the breast cancer detection team, plastic surgery nurses

provide a variety of roles and services for a patient having breast reconstruction. One important

role of the breast reconstruction nurse is to educate patients about their reconstructive choices.

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In this role, plastic surgery nurses are an asset and resource for patients and addressing their

questions and concerns about the procedure. After the reconstructive approach has been chosen,

the plastic surgery nurse will provide vital information and specific details about the procedure

and follow-up care. The educational sessions provided by the plastic surgery nurse included

various topics that are presented to the patient, her family members, and caregivers (see Figure

18.0).

The plastic surgery nurse’s role in education is very important, which is why she needs to

use various tools and pedagogical strategies to help her in this process. For example, the nurse

may use diagrams and pre-and post-photographs of women who have had the same

reconstructive procedure. Having the opportunity to speak with other patients who have

undergone similar reconstructive surgery is an important element to patients with breast cancer.

It is also important for these women to speak with patients who have utilized the same plastic

surgeon.

Using the strategy of providing pre-and-post photographs, diagrams, and verbal

explanations by the nurse, does not compare to hearing the first-hand experience from another

woman who has been down the path of reconstructive breast surgery. With the inception of

HIPAA regulations, the names of patients who have had similar procedures with the same plastic

surgeon must consent and agree to have their names given to other patients. Personal experience

shared by previous reconstruction patients gives patients personal insight and knowledge of what

to expect with their own upcoming surgery. This allows the patient to contemplate breast

reconstruction and align her expectations from this surgery.

Next, it provides the patient with a network system of communication, which will allow

her to share her concerns, fears, as well as her positive and encouraging beliefs. Many women

who have had previous reconstructive breast surgery are more than willing to provide a show-

and-tell demonstration with new patients. This allows the new patient to visualize what a

Educational Sessions by Plastic Surgery Nurse include:

❖ Procedure to be performed

❖ Anticipated treatments

❖ Safe medications and ones to avoid

❖ Diet and exercise recommendations before and after

surgery

❖ Risks and possible complications from surgery

❖ Pain and recovery expectations

❖ Smoking effects on healing

❖ Appropriate clothing needed for post-surgery

Figure 18.0 Source: Berger, Bostwick, and Jones, 2011; Photo by Unknown Author is

licensed under CC BY- NC-ND

37

reconstructed breast looks like, which in turn puts their mind at ease, reduces their stress, and

inner turmoil.

As mentioned previously, the plastic surgery nurse’s role as a resource comes in helpful

in many ways. For example, one important information that the nurse discusses with the patient

is the significance of clothing. This is vital as it reduces the patient’s stress level by one less

thing they must worry about and makes their life much easier. Having heard from previous

patients, the nurse explains to the new patient what type of clothing is best for pre-and-post

surgical comfort. According to previous patients who have had reconstructive breast surgery, the

best thing to wear is loose and baggy clothing, with buttoned-down front tops. The rationale,

according to these patients is because the loose tops are best for disguising the drains and

dressings during the first postoperative phase.

One major concern for patients with breast cancer is the financial costs for their

treatment. During the educational session with the nurse, she can discuss the patient’s insurance

coverage. Currently, most states in the U.S. require insurance companies to provide coverage for

breast reconstruction and for any surgery required for the symmetry of the opposite breast.

Another helpful suggestion from patients who have had breast surgeries is for new patients to list

questions that they may have for each individual team member. In addition, they also suggest

that the patient write down the answer to each question for reference later. This suggestion is

important because it ensures that all vital information is covered, and nothing is overlooked.

Plastic surgery nurses have a vast amount of experience and come from different

specialties, such as private offices, hospitals, nursing homes, and even operating and recovery

rooms. Consequently, patients who are having reconstructive breast surgery will have plastic

nurses with a high amount of expertise, knowledge, and experience. These characteristics are

important because they contribute to the recovery and care of these patients.

After the surgery has been performed, the patient is transferred to another section of the

hospital called the recovery room, in which the next breast cancer detection team assumed care

of the patient. The nurses in the recovery room will monitor the patient by taking her vital signs,

giving pain medication, and perform an overall recovery assessment. Depending on the patient’s

medical stability, the patient will stay in the recovery room for about 1 to 2 hours. This also

depends upon the patient’s recuperation from anesthesia. After the allotted time has passed, and

the recovery room nurse believes the patient is well oriented and alert, the patient is released. It

is noteworthy to mention that both the plastic surgical nurse and the recovery nurse may be

considered as silent caregivers as the patient is under anesthesia and may not be aware of their

significant roles in her breast cancer care.

Treating/Caring for Breast Reconstruction Patients: The Registered Nurse’s Role

However, once the patient is out of the recovery room and into her assigned hospital

room, she will encounter the acute care nurse. This is another specialty nurse that provides care

for the breast cancer patient and is a vital team member for breast cancer detection. Nurses have

multiple roles in hospitals and healthcare: patient safety, caregiver, communication, educator,

and patient advocate.

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Patient Safety

The role of this professional registered nurse (RN) is to ensure patient safety while

treating and caring for the patient during their hospitalization. Once the attending provider has

seen and treated the breast cancer patient, it is the nurse’s duty to prevent medication errors and

to ensure that the patient receives the correct treatment, procedures, and therapy. In addition, the

nurse must follow and adhere to the hospital’s policies and safeguards that are put in place for

patient safety.

Caregiver

It is the nurse’s role to care for the patient during the hospitalization for her breast

surgery regardless of whether it is a complete mastectomy, lumpectomy, with or without breast

reconstruction. In addition, the care delivered to a patient depends on the severity and stage of

the surgery, and the type of surgery the patient had. For example, if the patient had a

lumpectomy, the care provided by the nurse and educational sessions is different as opposed to if

the patient had a mastectomy with reconstructed surgery.

Communication

Communication is a major role for the registered nurse. The nurse needs to be able to

adapt her communication skills to the level of education of the patient. For example, patients

who are not educated require more in-depth communication and explanations than patients with

a higher level of education. Effective communication in healthcare is vital as it can improve the

outcome of patients with breast cancer. Consequently, the nurse’s role in communicating with

her breast cancer patient must be effective; otherwise, the healing process may be inhibited.

Educator/Teacher

Another role of the RNs is to prepare the patient for her upcoming discharge. The role of

the acute registered nurse is to teach the patient how to care for her surgical site, how to change

the dressings properly, and how to empty the surgical drain. In addition, the registered nurse well

explained to the patient how to take her medication as prescribed by her attending physician.

During the patient’s hospitalization, the nurse will also explain in detail the limitations and

restrictions of physical activities. This is an important part of the patient’s healing process as

excessive physical activity may injure the surgical site. For example, the drainage tubes may be

dislodged. It is during this hospitalization that the patient is given ample time to ask questions

about her surgery and the appropriate care for the affected breast site. Consequently, the

registered nurse takes advantage of these teaching sessions to facilitate the patient’s recuperation.

Patient Advocate

One main objective of healthcare management is to ensure that the care delivered is

affordable, efficient while meeting high standards of care. This role may be considered one of

the most significant of the nursing roles as it gives the nurse the ability to fight for the patient

39

rights. Usually, when a patient is not well, then it’s the nurse’s obligation to determine the

specific needs of the patient and ensure they are met. This may be challenging for many nurses,

as some physicians or surgeons may be intimating and difficult to work with. However, as a

patient advocate, the nurse is required to see to the safety of the patient.

Significance of Nursing Role

During the patient’s hospitalization, the patient receives attentive care 24 hours a day,

which means that they are typically the first person to detect a problem when it arises. Nurses

are skillfully trained to detect subtle changes in the patient’s vital signs, surgical site, or other

symptoms that may indicate a concern. By being alert, the RN can alert the plastic surgeon to

any possible changes in the patient’s condition, thereby adjusting or changing the care plan.

Registered nurses who treat and care for breast cancer patients with breast reconstructive

surgery are in a unique position to serve as caregivers, confidants, and support personnel. These

nurses can respond to the patient’s physical and emotional needs, as they are attuned to their

patients’ possible psychological condition. The nurse can respond and be prepared to help the

patient adjust to her surgical circumstances. They recognize that the reconstructive breast process

is not complete when the incisions are healed, but instead, the emotional healing process begins.

This is important to remember because when a woman loses a breast due to mastectomy, she

undergoes an emotionally devastating experience. She is overwrought and overwhelmed by her

emotions. Patients that are newly diagnosed with breast cancer need to be aware that her body

may be physiologically healed, but her emotional, psychological, and spiritual self may require a

longer time frame. This is when the RN can help and provide support to the patient.

Historically, patients who have undergone breast reconstruction claim that it takes at least

one whole year to adjust to the changes caused by breast cancer. This includes the changes in the

body due to chemotherapy, radiation, breast surgery, and reconstructive surgery. Thus, patients

who have undergone this ordeal, feel comfortable turning to their nurses for support and comfort

when coping with this process. One reason for this belief is because the patient feels the nurse

has a vast amount of experience helping similar patients who have undergone breast cancer

surgery. It is noteworthy to mention that this same rationale applies to patients receiving their

mammogram; thus, turning to the mammography technologist or comfort and support when

facing a possible breast cancer diagnosis.

Nursing - Community outreach

Nurses are key players in the fight against breast cancer and provide extensive support to

patients undergoing breast cancer treatment and surgical reconstruction. Nurses, in general,

regardless of the specialty field they work in, have become involved in community outreach

efforts. Their goal is to help women succeed in their fight against breast cancer. They have

become involved in organizing different types of support groups for patients facing the

challenges of breast cancer and breast reconstruction. These events and efforts are often led by

nurses, social workers, advocate recruiters, or other breast cancer detection team members.

40

Group support meetings help patients, family members, and caregivers educate

themselves about sharing feelings, expectations from reconstructive surgery, and provide

emotional and positive support. During these sessions or meetings. The women can discuss

private issues that they are otherwise hesitant to share with others who have not undergone breast

cancer or breast surgery. The most common topics include:

• issues of self-image

• mastectomy and reconstruction impact on sexuality

• body image

• dating and relationship concerns for the single woman

In addition to support groups, nurses involved in community outreach will also organize

and participate in other types of events. Many communities throughout the U.S., will sponsor

breast cancer relay events, health fairs, and fundraising events. For example, healthcare

facilities, organizations, and agencies will have fundraising dinners with silent auctions, and

engage community businesses by having them donate merchandise, products, or services.

Besides, organizations and agencies will take advantage of the October breast cancer awareness

campaign and provide services to low income or underinsured women.

These meetings and events play a significant role in patients who are fighting for their

lives and dealing with breast cancer. These groups, events, and services are made available to

women facing breast cancer and breast reconstruction, and their family or caregivers. They are

frequently encouraged to attend these events because they provide an accepting and positive

environment for sharing everyday experiences during their journey against breast cancer. More

importantly, patients are aware that they are not alone in this trying time.

Treating a Breast Cancer Patient: The Physician Assistants Role

A physician assistant (PA) works under the supervision of a physician, and his or her role

is like that of the doctor, but there are several differences and limitations. The major role of the

PA is to work with a doctor while delivering a broad range of services and treatments. There are

many areas of expertise where a PA can work. For example, the PA can work with any of the

breast cancer team providers such as the primary care provider, the surgeon, or the medical

oncologist. In addition, this position allows for the PA to work in almost any environment such

as clinics, hospitals, public health departments, or other outpatient ambulatory facilities.

Commonly, the PA works in a doctor’s private practice or an urgent care center. In the U.S., one

study reported there were about 106,200 PA’s employed in 2016, and more than 50% were

working in private physicians' offices (Doyle, 2019).

In many practices, the physician assistant assists the physician with the increasing patient

schedule and provides the doctor with assistance when needed. The PA’s key role is to manage

the treatment and care of the new in-coming patients, as well as for the existing patients. Their

responsibilities for treating breast cancer patients include performing physical examinations,

recommending and ordering diagnostic and laboratory tests, and managing cancer and treatment

side effects of chemotherapy. They are also responsible for prescribing medications and make

41

referrals to other specialists if needed. Next, as part of the breast cancer team, they will provide

input when creating treatment plans.

As a healthcare professional, another role for the PA is to be compassionate,

understanding, and passionate about treating patients with cancer. They must motivate and

encourage their patients to have healthy habits, have regular check-ups, as well as follow up

visits. Their next role is that of an effective communicator. It is very important for PA’s to

establish a close relationship with patients to build a rapport, which encourages the patient to

speak openly, frankly, and candidly. Last, as an educator and counselor, the PA will provide

vital information, counseling, and act as a resource about breast cancer and other related

material.

Caring for Breast Cancer Patient: The Oncology Social Worker’s Role

While almost everyone knows of the social worker, not very many people are familiar

with an oncology social worker and did not know they existed. An oncology social worker is a

specialized social worker whose key role is to provide psychosocial services to patients dealing

with a cancer diagnosis. One specific group they help are women with breast cancer. Plus, they

help not only the patient, but also the family members and caregivers. Oncology social workers

(OSW-C) are certification by the Board of Oncology Social Work (The Clearity Foundation,

2018). This specialized oncology social worker assists patients to cope with their breast cancer

and the challenges associated with the disease. For example, they may provide counseling, lead

support groups, locate financial assistance, or resources (Cancer.net, 2018). For an oncology

social worker, there are five key roles: clinical services, collaboration, program support and

development, documentation, and assessment (socialworkdegreeguide.com, 2019).

Clinical Services

One of the key roles oncology social workers is to provide basic clinical services to

breast cancer patients. Social workers in oncology departments, facilities, and wards will provide

clinical, psychosocial assessments, and support services to patients facing breast cancer. They

also teach the patient, family members, and caregivers coping mechanisms. The comprehensive

psychosocial assessments OSW complete ensure breast cancer patients receive specific services.

Also, the OSW will incorporate psychiatric evaluations to verify accurate diagnostic impressions

that are used to organize treatments, referrals, and resources, or discharge plans. They use their

educational knowledge and skills to provide specific care to their patients and use this knowledge

to recognize each patient's specific treatment, self-management, and discharge planning needs.

This Photo by Unknown Author is licensed under CC BY-NC-ND

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Last, they act as a patient’s advocate by recommending resources for the patient's needs, such as

emotional, spiritual, social, and financial assistance.

Collaboration

Collaboration plays a key role for OSWs who maintain a successful communication

system with the team providers related to the patient's psychiatric and psychosocial needs. These

healthcare experts maintain a positive operational relationship with management, administration,

and other departments to provide quality patient care. Following and adhering to designated

oncology policies and procedures is important to all OSWs. Working as a team member with

oncology nurses, the medical providers, and the treatment team members is an important role

when developing and delivering the patient's treatment plan. An essential role is to give patients

and their family members the necessary education to ensure the ultimate outcomes for their

treatment plans.

Program Development/Support

The third key role of OSW is program development and support. As a member of the

breast cancer detection team, the oncology social worker at this level must have a master's degree

and a current licensed clinical social worker (LCSW) license. This expertise is necessary when

managing an ongoing program that provides breast cancer patients with the support required for

a successful treatment plan. An important duty of the OSW involves case management duties in

which they perform:

➢ Utilization review

➢ Quality improvement

➢ Community resource development

Figure 19.0 illustrates other case management duties for the oncology social worker. In

addition to case management, they will match resources, assist with referrals, and develop

relationships with similar oncology departments in other facilities. They act as a liaison and

participate in committees, community, and internal departmental meetings. Developing and

evaluating policies and procedures for breast cancer care is commonly accomplished by a senior

OSW. Next, they review, evaluate, and analyze related laws and regulations which may affect

discharge planning and proposed treatments, then relay this information to administrative and

treatment leaders.

Documentation

An important component in healthcare is documentation, which is another key role for

OSWs. This phase consists of ongoing daily documentation of assessments, progress notes,

treatment plans, and referrals. With the inception of HIPAA, maintaining patient confidentiality

and privacy is legally mandated. Oncology social workers keep consistent and accurate

documentation of their services to patients to assist physicians in providing proper medical care.

They must ensure the patient’s information is in a secured storage area and not easily accessible

43

to non-authorized individuals. The type of activities that must be documented varies from facility

to facility, but many standard activities, state mandates must be documented, such as:

• initial psychosocial assessment

• proposed care plan

• discharge planning efforts

• collateral contracts

• insurance reviews

Oncology social workers are required to abide by the Clinical Social Work Practice (CSWP)

documentation guidelines (socialworkdegreeguide, 2019).

Discharge Planning

The last role for OSWs is to provide discharge planning for their patients or clients.

These OSWs have the capability to build positive interpersonal relationships with their patients

and community organizations that will assist breast cancer patients upon discharge. They will

initiate contact with private, county, and state agencies that provide resources for easy

facilitation of discharge planning that requires less restrictive levels of care. With independent

patients, the OSW will manage a caseload that requires constant follow-up and communication

with external clients. They provide information and referral services to patients, family members,

and caretakers related to community resources and state agencies. As OSWs assist with referrals

and provide resources, they must keep up to date with resources available and be knowledgeable

about the eligibility criteria for community services. For example, some programs and services

are available only to low-income or non-insured patients.

Oncology Social Worker – Case Management

✓ Aptitude with assisting patients adjusting to diagnosis ✓ Propensity with assisting patients accessing social services ✓ Knowledge with unique challenges of breast cancer patients and their caregivers ✓ Knowledge with primary medical treatment options for cancers ✓ Assistance with resource, such as childcare, transportation, palliative home care,

support groups, distance treatment lodging, etc. ✓ Overall understanding of disease, courses of treatment and common disease-

specific cancer experiences ✓ Understanding of complementary, holistic and integrative approaches to treatment

and disease management ✓ Aptitude with assisting patients with options for management of treatment side

effects ✓

Figure 19.0 Source: The Clearity Foundation, 2018

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Caring for Breast Cancer Patient: Patient navigator’ Roles

The patient navigator also called patient advocate, is a relatively new role found in breast

care and is becoming familiar in mammography facilities, outpatient centers, and hospitals. The

first patient navigator program began in Harlem Hospital in 1990, by a surgeon who wanted to

reduce the barriers to breast cancer faced by underserved populations (ACS, 2017). Originally,

the goal of patient navigation programs was to help patients overcome challenges like no health

insurance, low literacy, or poverty were preventing women from gaining access to medical care

and preventive services. For example, many women could not afford screening mammograms

because they had no medical insurance.

The key role of the navigator is to assist breast cancer patients in navigating through the

convoluted American health care system. This can be accomplished by guiding breast cancer

patients from the first step of diagnosis through survivorship. While patient navigators are

typically nurses, they can be other types of healthcare professionals, such as social workers or

volunteers (Cancer.net, 2018). A patient navigator will help a breast cancer patient find

counseling, financial aid, and other supportive services.

Over the years, various community-based navigation programs were initially developed

with the assistance of federal grants. Currently, patient navigator programs can be found

throughout the country with more than 100 American Cancer Society patient navigators across

the US (ACS, 2017). In addition, the American College of Surgeons Commission on Cancer

requires cancer centers to provide patient navigation services because illnesses like breast cancer

may be so complicated for patients to understand regardless of income or level of education.

Organizations are established to train patient navigators, establish standards, and expand

programs. Navigators are knowledgeable about community resources that offer grants that

provide financial assistance for transportation, utility bills, child or adult care, wigs, and breast

prosthetics. However, with the implementation of the Affordable Care Act state health insurance

exchanges are required to establish a navigator program to assist patients in making informed

decisions when obtaining health insurance. Patient navigators, whether they are a nurse, social

worker, or other health professionals, work with patients, families, and caregivers to meet with

various needs associated with breast cancer and the health care system:

While there is no exact list of duties for the patient navigator, their role continues to

change and expand. The patient navigator typically focuses on education and helping patients

comprehend the importance of screening and provide follow-up education. Some navigators will

* assisting caregivers

* finding medical providers

* explaining treatments and plans

* explaining care options and risks

* communicating with their health care team

* managing medical paperwork

* going with patients to visits

* helping with insurance problems

* assist with scheduling tests

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focus on helping certain populations, such as senior citizens or cancer patients, including breast

cancer.

Spiritual Aid for Patient with Breast Cancer: The Chaplain’s Role or other religious

support

Patient diversity varies from cultural and ethnicity, to spirituality. Women who face the

challenges of breast cancer often need spiritual support and faith-based rituals. The concept of a

higher power spirituality is one that breast cancer patients seem to seek. For female patients

diagnosed with primary breast cancer, emotional and spiritual support is an essential component

for their road to recovery. Most hospitals, cancer centers, and other health facilities have a

religious leader such as clergy on staff that works with patients of all denominations and faiths.

However, some patients prefer to seek guidance with their spiritual leader, such a Chaplain,

Rabbi, Father, Minister, or another type of church leader. Chaplains are a unique part of the

breast cancer team and are typically the only individual that a patient does not actually have to

see. While the rest of the cancer team is involved with physical symptoms, a chaplain has a

special place in patient care as they embed faith and help patients rediscover the faith and

inspiration they once knew. With breast cancer patients who are uncomfortable speaking about

their childhood, the chaplain can probe deeper into the patient’s emotional state. Chaplains can

assess a patient’s current situation, such as a new diagnosis, survivorship, or news of terminal

cancer that cannot be treated and use appropriate interventional strategies. Basically, their role is

to provide appropriate interventions regarding peace of mind, values of life, and death.

Chaplains focus on the patient’s internal struggles; which others may not see or be aware

of. These internal and unseen turmoil causes the patient unforeseeable pains that cannot be

treated with a scalpel or stethoscope. According to one chaplain, “The job of a chaplain is really

fairly simple, and that is to be a good listener to the patient and to help them find the threads of

strength in their life somehow,” (Fraga, 2014). A chaplain’s active listening skills are vital

because of the seriousness of breast cancer.

The first step toward healing is to bring awareness of the patient’s spiritual conflicts. The

open-ended questions presented in Figure 20.0, allow the chaplain to open the communication

door with the patient for cognizance of their spiritual pain. The second step is to provide more

practical and down-to-earth resources, which results in additional healing. Examples of practical

solutions include providing:

Transportation (to medical appointments, errands, church, other events, etc.)

Home visits (visiting at their home, chatting, reminiscing, etc.)

Running small errands (i.e., grocery shopping, paying bills, etc.)

Assistance with home chores (i.e., cooking, washing, cleaning, etc.)

Assistance with personal hygiene (bathing, clipping nails, hair styling, etc.)

46

Acts of kindness (i.e., positive phone calls, going to movies, washing car, etc.)

Join in prayer

The list of practical solutions provided for patients with breast cancer is endless. Ultimately, the

spiritual leader, being the chaplain or another, they are a key player in the fight against breast

cancer. They are the ones who can coordinate these efforts because of their connection to the

community.

The Spiritual Health Assessment, based on

“Healing the Four Dimensions of Spiritual Pain,”

• What is giving me life/energy right now?

• Who or what keeps me from being fully alive?

• Who or what do I need to forgive? From whom do I need to seek forgiveness?

• Who or what means the most to me?

• Who or what do I fear losing?

• What dreams keep me alive?

• What are my current inspirations?

• Why might I feel depressed or hopeless?

• What am I worried about?

• What are the things I want to get done or have people remember me for?

• Will my faith tradition play a role in the health care decisions I am making?

• What are some of the services I will need at the end of life?

Figure 20.0, Source: Boatwright, 2016

“The chaplain’s biggest

gift is to be present

and just listen.”

Picture is Public Domain. Quote is from Chaplain Marika Hull at St. Anne’s Hospital Cancer Center in Fall

River, Mass. (Fraga,2014).

47

Role of Medical Interpreter

Medical interpreters assist non-English speaking patients to communicate with their

medical providers or other team members in various medical facilities. In addition to working in

oncology departments, they may also work in numerous health settings, such as clinics, mental

health departments, hospitals, rehabilitation facilities, physician’s offices, home services, and

nursing homes. Due to the seriousness of breast cancer, this oncology team position requires the

interpreter to interpret accurately and plays a significant role in breast cancer detection.

As a team member in the detection of breast cancer, mammographers may encounter

health interpreters. Consequently, radiology technologists and mammographers must be aware of

the medical interpreter’s role and responsibilities. Although a medical interpreter’s daily

responsibilities and duties are determined by where they work, there are several basic duties and

obligations related to their role with breast cancer patients.

The main role of an oncology medical interpreter is to bridge the language gap between

the patient and the provider and other team members. The medical language is somewhat

complex, and the information given to the patients must be interpreted accurately, which means

they need a superior level of communication skills in a foreign and English language.

Consequently, the interpreter must be able to speak fluently in the patient’s own language and

ensure that the patient understands the medical information. They interpret a variety of medical

information that includes oncology terminology, mammography, and other procedures. In

addition, the interpreter needs to be familiar and able to interpret terms related to medication,

medical conditions and treatment, follow-up appointments, and other medical details.

While the main role of the oncology interpreter is to interpret, they must always remain

fluent. Consequently, medical interpreters, like all other medical professionals, must participate

in continued education and training to stay current with new technology, procedures, and

medical information. Technology and new innovative procedures are always changing, so

knowledge of new medical terminology related to these processes is important for effectively

interpreting information. Interpreters impart delicate and complex information, which means

they must always preserve patient confidentiality. While overcoming the language barrier

between patients and members of the breast cancer team, the medical interpreter adheres to the

facilities or hospital policies and procedures regarding HIPAA and confidentiality. While

fulfilling their main role, the oncology interpreter has many other duties, tasks, and

responsibilities, as illustrated in Figure 21.0.

This Photo by Unknown Author is licensed under CC BY-SA

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Another vital role of medical interpreters is to act as a patient advocate. Today, this role

may also be included in the duties of a breast navigator. Basically, a patient advocator’s role is to

ensure health professionals are acting in the best interest of the patient. Advocates will help

patients through their breast cancer diagnosis and treatment. Examples of their obligations

include:

❖ assisting them with coordination of medical appointments and breast team

❖ helping them with treatment choices

❖ assisting them in finding the right doctors

❖ provide background and research information in health and medicine

The medical interpreter who acts as a patient advocate needs to be politely assertive. As

they act in the best interest of the patients, they may encounter health professionals who may

resist the efforts of the advocate. This role is vital, especially when the patient does not speak the

language, is uneducated, and is unfamiliar with the healthcare system. The medical advocates

must speak up on behalf of the patient, regardless of being intimidated by medical professionals

such as surgeons or other doctors. In addition, patient advocates are reliable, knowledgeable

about health care, truthful, and have great verbal communication skills.

Of special note, in addition to medical interpreters, others serve as patient advocates such

as family members, hospital staff, nurses, social workers, or chaplains. Anyone who can fight for

the patient’s rights, ability to perform research, have creative ideas in solving difficult health

issues, good organizational and excellent time-management skills can act as a strong patient

advocate.

Other duties for the Medical Interpreter

▪ Assess patients and monitor them to ensure they understand

information being conveyed

▪ Relay information regarding patient’s cultural issues to

professionals

▪ Note down and monitor interpretation activities according to

hospital standards

▪ May be asked to translate written documents

▪ Always give reports to a manager or supervisor

▪ Observe, obtain, and receive information from all relevant sources

Figure 21.0. Source: JD&RE, 2019

49

Patient Concerns about Breast Reconstruction

There are many reasons why patients seek reconstruction surgery. Some patients will

look at the practical considerations of having breast reconstruction, such as comfort and

convenience, while other patients have psychological or aesthetic concerns. It is strongly

believed by experts that reconstructive breast surgery will bolster a woman’s sense of femininity,

sexual attractiveness, and self-confidence. On the other hand, many patients just want to have

peace of mind and more positive experience with their breast cancer. Consequently, one solution

for them is to realign their body image and recapture what they believe is their feminine

wholesomeness. No one solution or answer is appropriate for every single patient. Instead,

individualized beliefs and rationale for having breast surgery are warranted. The simple fact

exists that after a woman’s breast has been removed, her breast and chest area will be deformed.

This deformity affects patients differently in many psychological ways. A sense of loss is

measured differently among each patient. It is normal for many patients to desire restitution and

is a normal reaction to having one’s breast removed. Having breast reconstruction helps the

patient reaffirm her body image, thus providing internal harmony and increased positive self-

awareness. Fortunately, these women can rebuild and replace their missing breast(s) with the

assistance of surgical reconstruction, bringing back a positive environment, optimistic hopes, and

confident attitude for their future.

Within the last two or three decades, breast cancer treatments have undergone major

changes. Historically, the emphasis on cancer was primarily on removing cancer, but today,

treatment has a broader aim. In addition to tumor removal, there is now a focus on the quality of

life issues such as breast preservation or breast restoration. Irradiation preceded by a lumpectomy

has withstood the test of time as a viable and effective primary treatment for addressing breast

cancer. Patients who choose this option can be confident as to its success because the survival

rates are the same as those expected after mastectomy. Therefore, immediate breast

reconstruction following mastectomy, lumpectomy, and irradiation have become the norm. This

allows patients to have the most effective cancer treatment while preserving their breasts. This

process of breast reconstruction, especially immediate breast restoration, is no longer questioned

after mastectomy or after a lumpectomy, or partial mastectomy. Also, this process has

considerable aesthetic and psychological benefits.

Patients who are considering this option are not sure if they are appropriate candidates

and continue to have many questions about the safety of breast reconstruction. Many patients are

unsure if reconstruction can cause cancer or mask a recurrence, so they are unwilling to have

reconstruction. In addition, few patients are aware of all the technology currently available

regarding implants and the options of using all-natural tissue. They are hesitant to have implants

with foreign material in their breasts. Other patients have anxiety about the appearance of the

new breast, the appearance of breast scars, or the development of complications. Another

concern for other patients is the financial costs for reconstruction.

As breast cancer patients face reconstruction have so many questions, the breast

management team, including mammographers and other imaging technologist, need to become

50

familiar with these concerns, and the frequently asked questions, so they can respond if asked by

a patient. The following section will address the frequently asked question breast cancer patients

have and the appropriate responses.

It is important for a patient to know about the option of breast reconstruction. Many

women are not aware of all the options available to them when they face breast cancer and need

surgery. One reason a patient procrastinates in seeking medical attention for breast problems

such as lumps is due to fear of a malignant diagnosis and the consequence of losing a breast.

Consequently, cancer experts believe many patient’s lives would be saved if they knew that

breast reconstruction is an option for them.

The size and the severity of a patient’s cancer may influence whether she should have her

breast reconstructed. Patients with small tumors have the best prognosis for survival after being

diagnosed with breast cancer. Consequently, they are the easiest population to receive breast

reconstruction most frequently. For patients who decide to have a mastectomy and whose tumors

have been discovered in the early stages, immediate breast reconstruction is a viable and

appealing option. On the other hand, patients with larger breast tumors, which have spread into

the lymph nodes may also have their breasts restored. However, chemotherapy and radiation

therapy impact the timing of their operation. Using preoperative chemotherapy, patients with

larger tumors may have their tumors shrunk so that they can become good candidates for

immediate or staged breast reconstruction.

Patients may ask about the psychological benefits of breast reconstruction. There are

many benefits from having breast reconstruction, and each patient benefits in her own personal

and individual manner. Patients having immediate breast reconstruction often appreciate the fact

that they do not have to deal with the mastectomy deformity. According to research, patients

who have had immediate breast reconstruction feel better about themselves. Patients also stated

having this procedure gave them the freedom from having to wear a prosthesis. Last, some

patients claim that having immediate reconstruction on their breast saved them from the constant

reminder of having a mastectomy.

Patients, who are not appropriate for breast reconstruction have been presented, which

now leaves those patients who are candidates for breast restoration. One study found that most

breast cancer patients are candidates for breast reconstruction. Consequently, this choice is

commonly stated during the initial cancer team management meeting. The team experts explain

to the patient that her primary treatment can include an immediate breast reconstruction with

skin-sparing mastectomy upon her mastectomy surgery. One factor that is not significant is a

patient’s age when determining a woman’s suitability for this procedure. In addition, other

factors such as the placement of her mastectomy scar or her type of mastectomy are not relevant

either. With the advancement of technology, patients who have had lumpectomies, partial

mastectomies, or radical mastectomy’s in the past can now have satisfactory breast

reconstructions. Surgeons are performing more breast reconstructions now than in the past,

which has improved their surgical skills. Consequently, it no longer matters how much time has

elapsed since the patient’s had her original breast surgery. Studies show that patients have had

successful reconstructive breast surgery with exceptional results 15 to 20 years after mastectomy

51

(Berger, Bostwick, and Jones, 2011). In other words, there no statute of limitations for

reconstruction and no disadvantage to waiting.

Advanced Breast Cancer

As previously mentioned, some patients may not be candidates for breast reconstruction

due to their poor health. However, patients with advanced breast disease wonder if they are

eligible for this surgery. When cancer has spread into the lymph nodes, most patients will forego

this procedure. However, occasionally, a patient with advanced breast cancer will request this

surgical reconstruction. They want their breast reconstructed regardless of advanced cancer.

Their rationale stems from their belief in being “whole” again, even knowing death is imminent.

Nonetheless, the cancer management team will consider the patient’s current health status with

her desire for wholeness. If they believe the patient is fully informed about the surgery, has

strong motivation, and is psychological and emotionally stable, then they will consider her

request. By performing the breast reconstruction on a patient with advanced breast cancer, the

goal is to improve the quality of her remaining life, as opposed to saving her life.

Impact of Health and Lifestyles

Several patients wonder if there are a group or population of women who should not get

breast reconstruction. As society is very diverse, there are many patients who should not have

breast reconstruction for various reasons. A patient’s general health status may indicate she is not

a suitable candidate or this type of reconstruction. For example, a patient with Alzheimer’s

disease, a recent stroke or heart attack, uncontrollable diabetes mellitus, or a severe chronic

disease she should not be considered for this complicated procedure. Plus, they may not be a

suitable candidate if their personal circumstances suggest that they cannot successfully manage a

major change such as operation. Other characteristics, such as their motivations, spiritual

strength, and emotional state, suggest that they cannot effectively cope with the major surgery

and recuperation.

When considering any certain types of surgeries, there are health and life-styles

characteristics to consider that may impact the success of breast reconstruction. The health status

of the patient with breast cancer is a consideration when discussing breast reconstruction.

Autoimmune diseases or other medical conditions that cause healing problems may impair

potential reconstructive results. One condition is hemophilia, a rare blood disorder resulting in

clots not forming properly because the blood is missing blood-clotting proteins. Patients with this

condition may bleed for a long time after a surgical procedure. The team management experts

will inform patients with autoimmune disorders; the risk of reconstruction with implants can be

unsuccessful as the rate of flap failures is significantly high. Consequently, the patient should

first consult with her internist or rheumatologist before considering any type of reconstructive

surgery.

Other factors to consider that may impact the success of breast reconstruction are prior to

radiation therapy and medication. Patients with a history of prior radiation therapy may have less

success with their surgery than breast cancer patients with no history of radiation treatments. The

reason for this discrepancy is because radiation treatments reduce the blood supply of the skin

52

and underlying tissues, which causes poor healing or complications. Patients taking certain

medications that may affect blood clotting must be reviewed. If they are on immunosuppressive

medication or prednisone, they should take more caution regarding wound healing and

infections. Ultimately, consulting with the medical cancer team is the optimal choice to get the

safest breast reconstruction outcome.

One life-style behavior that impacts the success of surgery is smoking. Smoking

cigarettes is the leading cause of death in the United States, causing about 480,000 deaths

(1 in 5 deaths) every year (CDC, 2019). The effects of smoking can have a harmful effect

and negatively impact the success of any surgical procedure. Smoking causes damage to the

heart and blood vessels within the cardiovascular system. Thus, the patient is at risk of a heart

attack or stroke and high blood pressure. Nicotine significantly reduces the blood flow to the

skin and underlying tissues, which in turn may cause surgical wounds to not heal properly more

infections, implants may have to be removed, and flaps may fail to heal (Berger, Bostwick, and

Jones, 2011). The cancer management team will strongly encourage and advise the smoker

(patient) to discontinue smoking before and after surgery. Figure 22.0 illustrates other relevant

smoking facts.

As a medical condition, obesity is a health factor that impacts breast cancer patients who

are considering breast reconstruction. In 2016, the obesity prevalence rate was almost 40% and

affected about 93.3 million adults in the U.S. (CDC, 2018). The obesity prevalence rate among

women was lower in the highest income category than in the lowest- and middle-income

categories. This trend was noticed among white, Asian, and Hispanic women. Another trend

identified in the same study found no difference in obesity rates by income among black women

2017 Smoking Facts and Statistics

❖ 14 of every 100 (14%) adults in the U.S. aged 18 years or older currently smoked cigarettes

❖ 34.3 million adults in the U.S. currently smoke cigarettes.

❖ More than 16 million Americans live with a smoking-related disease

❖ Current smoking has declined from 20.9% (nearly 21 of every 100 adults) in 2005 to 14.0% (14 of every 100 adults) in 2017,

❖ Proportion of “ever smoked” who have quit has increased

Figure 22.0 CDC, 2019

53

(CDC, 2018). In other words, obesity rates are the same among black women, regardless of their

income. Obesity has a direct correlation to increased complication rates from anesthesia,

pneumonia, as well as blood clots, all of which impair a successful reconstruction process. Next,

because of their obesity, patients who have implant reconstructions have higher rates of

unsatisfactory results.

Many women are not aware of the time frame for scheduling their breast reconstruction.

When a patient is diagnosed with breast cancer, there are many issues and concerns she is

worried about. One such concern is the timing options for their breast reconstruction.

Fortunately, the patient has several options in this regard. First, her breast reconstruction can be

performed immediately following the patient’s lumpectomy or mastectomy. It can also be done

during the same hospitalization, but on another day. Next, she can have delayed-immediate

reconstruction, whereby tissue expanders are placed temporarily in patients who may require

radiation therapy. Some patients prefer to wait for an undetermined amount of time, but the

surgery can be performed on a delayed basis; a few days, several months, or many years after the

initial lumpectomy or mastectomy.

Today, many health facilities and medical centers have breast management teams

experienced in performing immediate breast reconstruction, so they can offer this option to

patients who are having a lumpectomy or mastectomy. Often their surgeons will refer to the

plastic surgeon in the team before the cancer surgery so that they can investigate the option of

breast reconstruction and the best timing for this operation. Immediate breast reconstruction is

now the most frequently performed, the ultimate decision about the timing of reconstruction

must be made by a fully informed patient in consultation and agreement with her cancer surgeon

and her plastic surgeon to ensure the best treatment for her cancer.

Immediate and delayed reconstruction

Immediate Reconstruction

Immediate breast reconstruction has shown to provide the best aesthetic results and is

widely regarded as the approach of choice. Unfortunately, it is not appropriate for every patient.

This is especially important since more breast cancers are being discovered at an early, which

54

means a more curable stage. Patients diagnosed with breast cancer are the natural and obvious

choices for immediate breast reconstruction if breast-conserving surgery is not selected.

Appropriate candidates are patients in good health and with small tumors. Small tumors are

classified as those about 1 inch in diameter or less and do not involve axillary lymph nodes. If

there is cancer in the lymph nodes indicates that cancer has spread beyond their breast tissue. Of

these early cancer patients, those that are particularly appropriate for an immediate

reconstruction procedure include patients:

with a strong desire for breast preservation

with small breasts

who require bilateral reconstruction

who require partial reconstruction after lumpectomy

Delayed Reconstruction

Patients who had a mastectomy before reconstructive procedures is a natural candidate

for delayed reconstruction. Those patients with positive lymph nodes, require additional therapy

to treat her cancer, is also an appropriate candidate for a delayed procedure once chemotherapy

and radiation therapy is completed. Another candidate is the patient who needs time to evaluate

whether she wants breast reconstruction. The delay between the mastectomy and the

reconstruction gives her the opportunity to get acquainted with her plastic surgeon.

A different approach can be taken in which a tissue expander is inserted at the time of

mastectomy, to create an impression of a breast mound reconstructed. This delayed-immediate

reconstruction allows a patient to have the appearance of a breast while deferring the definitive

reconstruction until after her radiation or chemotherapy treatments are complete. In addition, it

gives the patient a semblance of a breast until the delayed reconstruction can be performed. This

device is then removed, and a definitive reconstruction with an implant or with her own tissue

can be performed after her recovery from radiation therapy.

Advantages and disadvantages of immediate reconstruction

Advantages

There is a certain psychological appeal for many patient’s having immediate

reconstruction, or reconstructive surgery performed at the same time as her cancer surgery. There

are also many advantages to obtaining an immediate reconstruction with optimal results. Dealing

with a life-threatening disease and simultaneously coping with the loss of a breast is devastating

to most women. Some patients will delay seeking a mammogram or seeing a doctor because they

fear a negative diagnosis.

Some women with breast cancer will not consider a mastectomy unless they have the

option of having an immediate breast reconstruction to avoid mastectomy deformity. A study of

women in their 20s and 30s who had chosen to have a mastectomy and immediate breast

reconstruction reported that immediate reconstruction was a powerful necessity for them to

adjust to their diagnosis. Second, they reported that with the immediate reconstruction, they felt

more at ease and able to conduct normal social lives. Another crucial advantage for these

55

participants was to be able to interact easily with the opposite sex and appear “normal” among

their peers. This makes all patient feel that their doctors are addressing not only their cancer, but

their overall well-being, issues, and health. There are several psychological and aesthetic

advantages associated with an immediate procedure. For example, patients have a high rate of

satisfaction and are extremely pleased with their decision. It is also a motivational step as they

believe the breast management team is sending them a positive and encouraging message that her

prognosis is positive enough to justify beginning their rehabilitation without delay.

Studies have reported that the survival rate of immediate breast reconstruction patients is

about the same as that of patients who have not had reconstructive surgery. Reports also illustrate

that the local recurrence rate for breast cancer is no higher in this group. Other studies report that

immediate reconstruction has positive psychological benefits for a patient whose desire is to

avoid breast loss. Patients do not feel overwhelmed or preoccupied with cancer. Another

advantage of immediate reconstruction is that these patients are extremely satisfied with the

result of their immediate surgery. They experienced less overall psychological trauma associated

with their mastectomy. Their new breasts are accepted more quickly into their new body image

while exhibiting less stress. One belief for this concept is because the patient awakens from her

mastectomy with a new breast in place and do not see the mastectomy deformity. Consequently,

the experience of mutilation from the breast amputation is not felt by patients who have

immediate reconstruction.

Many plastic surgeons believe the aesthetic results from immediate reconstruction are

better than those obtained with delayed reconstruction. Collaboration among the plastic surgeon

and the oncologic surgeon has led to key advances in technique, resulting in a more attractive

reconstructed breast. Often reconstruction allows the surgeon to remove less skin than would

ordinarily be removed for a mastectomy alone. This makes the breast scare shorter, a technique

called skin-sparing mastectomy (Berger, Bostwick, and Jones, 2011). It is only appropriate for

patients if there is no tumor involvement in the skin. By using this technique, the surgeon

removes the nipple-areola area with as much skin as needed for ideal tumor replacement. The

smaller scar is hardly visible since it is covered by the nipple-areola at reconstruction. The

preserved skin used to cover the new breast reduces the need for skin expansion. This is an

important element of the surgery because it means less skin is needed from the back, buttocks, or

abdomen when autologous breast reconstruction is chosen. The surgeon can preserve the natural

landmarks of the breast, such as the inframammary fold, medial cleavage, and the lateral area of

the breast. These natural boundaries play a significant role when having a mammogram as the

technologist uses them for accurate positioning. Plus, the boundaries can accurately define the

patient’s breast shape. Fortunately, the reconstructed breast aligns with the other remaining

breast for an optimal symmetry appearance.

Another advantage to immediate breast reconstruction is a quicker resolution of the

mastectomy deformity and reduces the number of operations the patient needs to have without a

longer hospitalization. The benefits are seen in the reduced cost of having one surgery with one

anesthesia performed during one hospitalization. Another advantage of immediate

reconstruction is that it saves time for the patient and the team management. For example, the

56

patient can recover from her mastectomy and the breast reconstruction simultaneously, without

having to schedule another surgery for the reconstruction later.

Disadvantages

One big disadvantage of immediate reconstruction is that the patient is put under more

stress because so many decisions must be made at once and very little time to consider all the

facts. A second disadvantage is that she will have more surgeries at the time of the initial surgery

(mastectomy). In addition, the patient will need another, and sometimes a third procedure to

complete her surgical process. This depends on the type of breast reconstruction she selects. As a

result, this will increase her hospitalization time, recovery time, and initial cost. In addition, the

success of the reconstruction depends on the patient’s healing process, and the expectations and

skills of the surgeon. Moreover, patients need to be made aware that the breast reconstruction

process will not be complete with only one operation.

With immediate breast reconstruction, inserting an implant or expander does not require

more time to perform as that of the original mastectomy. Disadvantages exist as a result of the

complexity of the operation. For example, complications may arise from hematoma, skin loss,

and infection with immediate reconstruction. Other complications may arise with implant and

expander reconstruction, such as:

• fluid accumulation in the mastectomy wound

• low-grade infection

• fibrous formation around an implant

• possibly resulting in capsular contracture

• hardening of the reconstructed breast

If infection occurs, the expander can be removed to allow time for the tissues to heal

before once again attempting a reconstruction. Again, this is a complication that may occur,

which results in delayed time. The advancement of technology has made new skin-sparing

techniques more remarkable, but there are still significant differences compared to natural

breasts. Patients who chose to have immediate reconstruction must have realistic expectations

about her breast appearance after immediate reconstruction. This leads to another disadvantage

to immediate reconstruction as her breast will not be an exact replica of her natural breast that

was removed.

While there are great benefits of having a cancer management team, there are also

disadvantages. Close teamwork between all the key team members can be difficult to accomplish

as they are all very busy; coordination is challenging as time conflicts are a major problem. In

addition, everyone on the team has a different personality, communication style, and

expectations. Consequently, team cohesiveness and the ability to work together may arise in

problems and conflicts. For example, the cancer surgeon must work with the plastic surgeon to

plan and perform the breast reconstruction, so they must be able to communicate and work

together for the benefit of the patient. There are obvious benefits and risks to be considered with

reconstruction and are summarized as follow in Chart 4.0:

57

Chart 4.0. Source: Berger, Bostwick, and Jones, 2011

Advantages and disadvantages of delayed reconstruction

Advantages

As with immediate reconstruction, delayed reconstruction of the breast also has

advantages. Delayed reconstruction can be done from a few days or up to years following her

mastectomy. This late period gives a patient more time to deal with her cancer. Studies of

women who delayed breast reconstruction reported that they felt delaying their surgery was

beneficial because it allowed them to investigate the reconstructive surgery process. For

example, they had time to speak to other women who had the same operation they were

contemplating. Consequently, they have more realistic expectations of their results that could be

accomplished. In the same study, the participants who had delayed reconstruction all felt that a

waiting period allowed them personal time to adjust and cope with their cancer diagnosis,

organize their emotional lives, and put other things in order. Besides, this time frame gave them

the time needed to adjust and separate the negative cancer experience from the positive

reconstruction experience.

When breast cancer is first diagnosed, a patient is overwhelmed and may need time to

fully assess her decision to have breast reconstruction, so delaying her surgery is the best option.

However, many patients change their minds after a waiting period and decide not to pursue this

option after postponing her reconstructive surgery. They give the cancer management team many

different reasons as to why they have changed their minds. For those patients that do not change

their minds, this delayed time frame gives them time to find the best plastic surgeon, get to know

him, and then decide on the correct reconstructive approach best suited for her. Also, the extra

time gives her the opportunity to recover from any additional radiation or chemotherapy that

* Probable improved aesthetic

results

* Shorter mastectomy scar

* Improved sensation

* Less psychological trauma due

to mastectomy experience

* Reduced overall operative,

anesthesia, and recovery

time

* Lower overall cost

* Less in-patient hospitalization

Benefits* More complex procedure to coordinate

* Less time for a woman to cope with a cancer diagnosis and evaluate her options

* Minimally higher complication rate

* Longer initial operative, anesthesia, and recovery time

Risks

58

might be required and to fully explore the topic of reconstruction. There are many forums and

mediums she can use to investigate breast reconstruction, such as social media, research

universities, hospital libraries, support groups, or other community resources.

Another advantage of delayed reconstruction is the psychological benefits for the patient.

For example, the general surgeon and plastic surgeon commonly prefer to ensure the patient

completely understands the extent of her cancer, diagnosis, prognosis, and the anticipated

treatment plan before they begin her surgery. This is particularly important and crucial if there

are other health considerations that must be dealt with. Plus, the plastic surgeon may believe a

delay in the operation may offer the patient more time to be committed to her procedure. The

last advantage to delay breast reconstruction relates to the plastic surgeon. With delayed

reconstruction, the plastic surgeon has more time to implement a successful plan for the surgery

in order to achieve accurate breast symmetry. Also, he will have better control of the variables,

than when an immediate reconstruction operation is initiated at the end of a mastectomy.

Disadvantages

One distinct disadvantage of a delayed procedure is the time frame that a patient must

endure when she does not have her breast. This can cause emotional and psychological damage

to the patient. Another disadvantage relates to the scars caused by delayed surgery. Patients who

have immediate breast reconstruction, have better results because more skin is removed during a

delayed reconstruction causing the scars to be longer. A second operation also involves another

hospitalization with the associated risks of general anesthesia, recuperation time, additional pain,

and financial costs. Occasionally, some patients who do not have this procedure at the time of

their mastectomy may not have the opportunity for breast reconstruction in the future. Again,

there are risks and benefits associated with a delayed procedure (see Chart 5.0).

Time to:

*make an informed decision

*get acquainted with the plastic surgeon

*recover from a mastectomy

*recover from adjunctive therapy

Benefits*time to dwell on cancer and deformity

*more skin removal, longer scar from initial mastectomy

*depression from a mastectomy status

*additional cost of 2 surgeries

*potential problems from 2 surgeries and 2 anesthetics

*never “got around” to having reconstruction

Risks

Chart 5.0. Source: Berger, Bostwick, and Jones, 2011

59

References

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Berger, K., Bostwick, J., and Jones, G. (2011). A Women’s Decision. St. Louis, Missouri:

Quality Medical Publishing, Inc.

Boatwright, L. (2016). What Is the Role of a Chaplain in Cancer Care? Retrieved from

https://www.cancer.net/blog/2016-04/what-role-chaplain-cancer-care

Cancer Treatment Centers of America (CTCA). (2019). Breast Cancer. Retrieved from

https://www.cancercenter.com/cancer-types/breast-cancer/treatments

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Mammography: A Team Approach to Fighting Breast Cancer

TEST

1. The goal of teamwork is to _____________ by increasing the survival rates of patients with

breast cancer.

a. communicates

b. reduce stress

c. enhance patient care

d. collaborate

2. According to the National Cancer Institute, if a patient is diagnosed with breast cancer, and

it is determined the cancer is at Stage O, then the patient has a ____ 5-year survival rate.

a. 22%

b. 72%

c. 93%

d. 100%

3. The ____________ is a specialist that serves as the patient’s primary care physician for

most women and often is the only doctor that they can visit on a regular basis.

a. Obstetrician-gynecologist

b. Medical Oncologist

c. Radiation Oncologist

d. Oncology Nurse Practitioner

4. It is vital for patients to meet the three team members from the breast cancer team, and they

include all the following EXCEPT:

a. Breast specialist

b. Radiation oncologist

c. Medical oncologist

d. Oncology Nurse Practitioner

5. If a patient or her physician locates a suspicious mass, lump, thickening, or other

abnormality in the breast, the patient should be scheduled for a _______________.

a. screening mammogram

b. diagnostic mammogram

c. stereotactic biopsy

d. MRI scan

6. Using a __________-dose radiation mammographic machine, the mammographer performs

the images of the breasts by applying radiologic precautions to ensure the patient is

protected from _____________ levels of radiation.

a. high, low

b. average, excessive

c. low, high

d. medium, low

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7. Which of the following statements is TRUE about MRI and Radiation Therapist’s role in

breast cancer detection?

a. MRI scanner uses strong magnetic fields, radio frequencies, use ionizing rays;

Radiation therapy uses low-energy machines that kill cancer cells.

b. MRI scanner uses strong magnetic fields, radio frequencies, but do not use ionizing

rays; Radiation therapy uses linear accelerators machines to kill cancer cells.

c. MRI scanner uses low magnetic fields, wave frequencies, but do not use ionizing rays;

Radiation therapy uses radio waves machines that kill cancer cells.

d. MRI scanner uses strong magnetic fields, radio frequencies, and use ionizing rays;

Radiation therapy uses radio frequency machines that kill cancer cells.

8. The pathologist’s plays an important role as a specialized doctor in the analyzing, diagnosis,

and reporting diseases in the laboratory.

a. True

b. False

9. Read the following statements and determine the CORRECT option.

1. The 3 types of oncologists are: radiation, medical, and surgical.

2. The radiation oncologist’s role is to determine when to use radiation.

3. Patient education is one of the radiation oncologists most important roles.

a. Only “1” and “2” are correct

b. Only “2” and “3” are correct

c. They are all FALSE

d. They are all CORRECT

10. Which of the following is NOT a question a patient might ask the Medical Oncologist?

a. Why are drugs used to treat cancer?

b. Why are there side effects of radiation therapy?

c. Why are there side effects of chemotherapy?

d. Why does my blood cell count have to be checked every time I go for

Chemotherapy?

11. Patients seek the assistance of plastic surgeons for aesthetic breast operations to:

a. enlarge their breasts

b. reduce their breasts

c. alleviate their breasts

d. All the above

12. The plastic surgery nurse provides educational sessions to the patient, her family members,

and caregivers. Which of the following is NOT a topic she will cover?

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a. procedure to be performed

b. medical billing

c. medication

d. pain and recovery expectations

13. Which of the following is NOT part of the roles of a Registered Nurse while treating and

caring for patients with breast cancer?

a. patient safety

b. medical interpretation

c. caregiver

d. patient advocate

14. During group support meetings, patients can discuss private issues that they are otherwise

hesitant to share with others - topics such as _______________________.

a. dating

b. cost of procedure

c. complications of procedure

d. advance directive

15. An important role of the Oncology Social Worker (OSW) involves case management – the

duties in which they perform include:

a. Utilization review

b. Quality improvement

c. Community resource development

d. All the above

16. The key role of the ____________is to assist breast cancer patients in navigating through

the convoluted American health care system, and from their first step of diagnosis through

survivorship.

a. nurse

b. radiologist

c. patient navigator

d. chaplain

17. The chaplain’s active listening skills are vital because of the seriousness of breast cancer, and

as Chaplain Marika Hull quoted, “The chaplain’s greatest gift is to be present and just

_______________.”

a. recite the bible

b. be compassionate

c. provide home visits

d. listen

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18. Read the statements below regarding patients concerns about breast reconstruction and

choose the correct answer.

1. Experts believe reconstructive breast surgery will bolster a woman’s sense of femininity.

2. Patients may ask about the psychological benefits of breast reconstruction.

3. Smoking does not impact the success of breast reconstructive surgery.

a. They are all TRUE

b. They are all FALSE

c. Statements “1” and “3” are both TRUE

d. Statement “3” is FALSE

19. Many plastic surgeons believe the ------------ results from immediate reconstruction are better

than those obtained with delayed reconstruction.

a. aesthetic

b. mastectomy

c. lumpectomy

d. scarring

20. When breast cancer is first diagnosed, a patient is overwhelmed and may need time to fully

assess her decision to have breast reconstruction…….

a. so, delaying her surgery is the best option.

b. being compassionate will help her.

c. convince patient to have surgery immediately.

d. but ultimately, it is the breast surgeon’s decision.