mammography: a team approach to fighting breast cancer · condition have a significant impact on...
TRANSCRIPT
1
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
2
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
3
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
4
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
5
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%
6
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
7
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
8
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.
9
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
10
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
11
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
12
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
13
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
14
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
15
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
16
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.
This Photo by Unknown Author is licensed under CC BY
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
19
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.
This Photo by Unknown Author is licensed under CC BY-ND
20
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
21
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.
This Photo by Unknown Author is licensed under CC BY
22
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
This Photo by Unknown Author is licensed under CC BY-SA-NC
23
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
24
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
25
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
26
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
27
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
28
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.
29
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
This Photo by Unknown Author is licensed under CC This Photo by Unknown Author is licensed under CC BY-SA
30
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
31
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
32
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).
34
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.
36
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.
38
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
42
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
44
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
45
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
48
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
ACS. (2017). Patient Navigators Help Cancer Patients Manage Care. Retrieved from
https://www.cancer.org/latest-news/navigators-help-cancer-patients-manage-their-care.html
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
Cancer.net. (2018). The Oncology Team. Retrieved from https://www.cancer.net/navigating-
cancer-care/cancer-basics/cancer-care-team/oncology-team
Cancer.net. (2019). Breast Cancer: Statistics. Retrieved from https://www.cancer.net/cancer-
types/breast-cancer/statistics
CDC. (2018). Adult Obesity Facts. Retrieved from https://www.cdc.gov/obesity/data/adult.html
CDC. (2019). Current Cigarette Smoking Among Adults in the United States. Retrieved from
https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
Decker, F. (2019). Job Duties of an MRI Technologist. Retrieved from Work - Chron.com,
http://work.chron.com/job-duties-mri-technologist-13052.html.
DerSarkissian, C. (2017). What are the 5-year survival rates with each stage of breast from cancer?
Retrieved from https://www.webmd.com/breast-cancer/qa/what-are-the-5year-survival-rates-
with-each-stage-of-breast-cancer
DeSantis C.E., Ma, J., Goding-Sauer, A., Newman, L.A., and Jemal, A. (2017). Breast cancer
statistics, 2017, racial disparity in mortality by state. Cancer J Clin.
Doyle, A. (2019). What Does a Physician Assistant (PA) Do? Retrieved from
https://www.thebalancecareers.com/physician-assistant-job-description-salary-and-skills-
2061819
FDA.gov. (2019). Ultrasound Imaging. Retrieved from https://www.fda.gov/radiation-emitting-
products/medical-imaging/ultrasound-imaging.
Fraga, B. (2014). Chaplain connects with cancer patients. Retrieved from
https://www.clarionledger.com/story/life/2014/11/07/chaplain-connects-cancer-
patients/18672753/
60
Guenin, M. (2019). Stereotactic Breast Biopsy. Retrieved from
https://www.radiologyinfo.org/en/info.cfm?pg=breastbixr#overview
JD&RE. (2019). Medical Interpreter Job Description, Key Duties and Responsibilities. Retrieved
from https://jobdescriptionandresumeexamples.com/medical-interpreter-job-description-key-
duties-and-responsibilities/
Kaplan, D.A. (2015). Why Aren’t There More Female Radiologists? Retrieved from
https://www.diagnosticimaging.com/practice-management/why-arent-there-more-female-
radiologists.
Kelly, A., Kelly, A.M., and Kopman, J. (2008). The developing role of mammographers in
performing sentinel node injections in a specialist breast care center. Retrieved from
https://breast-cancer-research.biomedcentral.com/articles/10.1186/bcr2054.
Ray, L. (2019). "What Are the Benefits of Teamwork in a Hospital?" Retrieved from
http://work.chron.com/benefits-teamwork-hospital-9073.html.
Social Work Degree Guide (2019). 5 Job Duties of an Oncology Social Worker. Retrieved from
https://www.socialworkdegreeguide.com/lists/5-job-duties-of-an-oncology-social-worker/.
The Clearity Foundation (2018). The Clearity Foundation-Ovarian Cancer Project Job
Description: Lead Oncology Social Worker (OSW) Gynecologic Cancer Specialty. Retrieved
from https://www.clearityfoundation.org/wp-content/uploads/2018/04/Oncology-Social-Worker-
Job-Description-Final.pdf
Truity.com. (2019). Radiation Therapist. Retrieved from https://www.truity.com/career-
profile/radiation-therapist.
Walter, M. (2018). 3 key statistics about gender disparity in radiology around the world.
Retrieved from https://www.radiologybusiness.com/topics/leadership/3-key-statistics-about-
gender-disparity-radiology-around-world.
Images
Mammogram. January 20, 2013. Provided by: Wikimedia Commons. Located at:
https://commons.wikimedia.org/wiki/File:Woman_receives_mammogram_(1).jpg. License:
Creative Commons CC0.
Radiologist. Provided by: Google.com Located at: https://www.army.mil/article/195404/annual
_mammograms_recommended_for_women_over_40. License: Labeled for reuse
All other pictures are Public Domain available at: Google.com and Yahoo.com
61
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
62
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?
63
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
64
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.