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Breast awareness: educating and informing women

Nicola West
RGN BN ENB All PGFETC(CertEd)
MA Counselling
Senior Breast Nurse Specialist
Cardiff Breast Unit
University Hospital of Wales, Cardiff

The breast is a rather unique organ, not only because it plays a vital role in a woman's ­femininity, but also because it can be a source of extreme anxiety and fear. It changes in shape and size from puberty through pregnancy and at menopause - and it is very important that women understand these normal changes. Breast care incorporates the care of the woman, not just those with breast cancer, but also those with any type of benign condition. The practice nurse, who is often the first line of contact, is in an ideal position to educate and reassure women and promote breast awareness.

Breast disease
Breast disease is very commonly seen in general practice: a GP can see up to 30 new cases per 1,000 women a year. The types of presentations can range from breast pain to cancer (see Tables 1 and 2).

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In the UK, breast cancer is the most common cancer in women, with an estimated 35,000 new cases diagnosed each year.(1) The lifetime risk for a woman has increased from one in 12 in 1988 to one in 10 now. Much of this increase has been associated with the National Breast Screening Programme, which hopes to increase the age ­criteria of screening from 50- 64 years to 50-70 years. Male breast cancer is far less common, accounting for approximately 1% of all breast cancers. Earlier ­detection and improved treatments have been ­responsible for a dramatic fall in mortality from breast cancer, from 19,000 seven years ago to approximately 13,000 deaths occurring each year now.(1) 
Benign breast disease is far more common than breast cancer - 14 of every 15 referrals to a specialist unit result in a benign condition.(2) This includes breast pain. Two of every three women will suffer from breast pain at some time during their life,(3) and it is the most common breast problem for which women consult their GP.(4,5) Fibroadenomas (fibrous lumps), cysts, nipple discharge and diffuse nodularity (general lumpiness) are other benign breast problems that may present. 
Women may also attend their local GP practice for consultation on breast corrective surgery, for example breast augmentation and breast reduction. The psychological problems associated with any breast condition, especially breast cancer, can cause extreme anxiety and depression. A total of 25% of patients who have undergone surgery suffer from anxiety and depression, and one-third suffer from sexual problems.(6)

Treatment for breast disease

Breast cancer
Over the last ten years treatment options for breast cancer have improved considerably (see Table 3), and breast ­conservation is the more ­modern choice of treatment with the same long-term ­survival.(7) In addition, women have been empowered by ­having a choice of treatment. Many of the main breast units throughout the country offer breast reconstruction as an immediate procedure to all women requiring a mastectomy. New techniques, such as skin-sparing mastectomy, nipple reconstruction and prophylactic mastectomy, are also now available. Improvement in patient care is evident with many patients discharged from hospital much sooner, giving them greater ­control. This has implications for the practice nurse in terms of referrals and contact.

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Chemotherapy and radiotherapy have improved and are now better tolerated and less feared. There are more clinical nurse specialists in breast care who are trained in the traditional role of providing ­ongoing support and care to women, from diagnosis through to recovery. There are also nurse practitioners in breast care who have more of a medical role in the diagnosis and treatment of breast cancer. Nurse consultants are also a new development and a way forward, but as yet there are no nurse consultants in breast care in the country. It should be pointed out, however, that the adoption of specialist roles must be accompanied by specialist education and training as well as professional support from the multidisciplinary breast team.

Breast pain
Treatment for benign breast pain is very ­successful and there are now many drugs available for effective control, for example concentrated ­prescription gamolenic acid. The practice nurse has a vital role in providing information with regard to sufficient doses, compliance, diet, smoking and bra type and fitting.

Hormone replacement therapy
The issue of hormone replacement therapy (HRT) and breast cancer is still very controversial. It appears that less than two years' use has no increased risk for women, but long-term use has been linked with an increased risk. Five years' use would equate to two extra cancers in every 1,000 women, 10 years would mean six extra cancers and 20 years would be 12 extra cancers. Five years after stopping HRT, this risk ­disappears.(8) Mammogram sensitivity is lower in women who take HRT and therefore makes ­interpretation more difficult. HRT has many benefits for women, including decreasing the risk of heart disease and ­osteoporosis and improving quality of life. The ­benefits and disadvantages need to be ­discussed with each individual woman so that an informed choice can be made. For women with a low-grade ­cancer of the breast, HRT can still be prescribed.

National Breast Screening Guidelines
The introduction of the National Breast Screening Guidelines in 1995(9) helped GPs in the referral of patients to specialist units. They highlight symptoms that require urgent referral and give guidance on the general management of breast problems, so that urgent cases can be dealt with more quickly. The guidelines also help prevent inappropriate referrals. Since the introduction of the Calman-Hine recommendations,(10) which ensure better ­standards of care for cancer patients, and the establishment of Rapid Access Breast Units throughout the country, GPs are able to fax urgent referrals across to the units and patients are seen promptly. There are also now family history and genetic centres around the country that GPs can refer to directly should women present with anxiety about family history risk.
The implications of the National Breast Screening Guidelines for practice nurses are that more practice nurses are dealing with breast care patients at the frontline and therefore breast ­awareness education is ­essential, not just for the patient but also for the nurses themselves.

Breast palpation
There is currently a diversity of practice among nurses in the UK in the use of breast palpation. Breast palpation alone is not a valid diagnostic or screening tool.(11) It is valid only as part of a triple assessment carried out in a specialist unit. Practice nurses are therefore discouraged from palpating the breast,(12) but they should encourage a woman to get to know her own breasts and become familiar with what is normal for her. This should be part of general body awareness.
Nurses should also take a particularly active role in the care of women with physical and psychological learning disabilities, and there is now a Makaton ­teaching pack available to help women using pictures rather than words.

Conclusion
Breast care is advancing rapidly and the primary care team is the first line of contact for many women. The rapid advances in treatments, practice and policy issues, and increased awareness by the public means that practice nurses will be increasingly involved with larger numbers of women and their families, ­especially those worried about breast cancer. Much of this ­anxiety and fear can be allayed by the practice nurse through increasing understanding of the whole ­spectrum of breast care. 
Practice nurses have a vital role in providing ­education, support and information and liaising with other healthcare professionals. Women are more vocal and involved in their care, their options and their rights, and nurses need to remain updated to keep up with this demand.

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References

  1. Cancer Trends in England and Wales 1950-1999. Appendix A. Key cancer statistics UK.
  2. Cochrane RA, Singhal H, Monypenny IJ, Webster DJT, Lyons K, Mansel RE. Evaluation of general ­practitioner referrals to a specialist breast clinic according to the UK National Guidelines. Eur J Surg Oncol 1997;23(3):198-201.
  3. Hughes LE, Mansel RE, Webster DTJ. Benign disorders and diseases of the breast. London: Bailliere Tindall; 1989. p. 75-92.
  4. Nicholas S, Waters WE, Wheeler MJ. Management of female breast disease by Southampton General Practitioners. BMJ 1980;281:1450-3.
  5. Roberts MN, Elton RA, Robinson SE, French K. Consultations for breast disease in general practice and hospital referral patterns. Br J Surg 1987;74:1020-2.
  6. Fallowfield LJ. Quality of life ­measurement in breast cancer. J R Soc Med 1993;86(1):10-12.
  7. Fisher B, Redmond C, Poisson R, et al. Eight year results of a randomised controlled study comparing total ­radical mastectomy and lumpectomy with or without radiation in the ­treatment of breast cancer. N Engl J Med 1989;320:822-8.
  8. Collaborative Group on Hormonal Factor in Breast Cancer. Breast cancer and hormone replacement therapy: collaborative reanalysis of data from 51 epidemiological studies of 52,705 women with breast cancer and 108,411 women without cancer. Lancet 1997;350:1047-59.
  9. Austoker J, Mansel R, Baum M, Sainsbury R, Hobbs R. Guidelines for referral of patients with breast problems. 2nd edn. Sheffield: NHSBSP; 1999.
  10. Expert Advisory Group on Cancer. A policy framework for commissioning cancer services [Calman-Hine report]. London: Department of Health; 1995.
  11. Department of Health. Clinical examination of the breast. Joint CMO/CNO Advisory Letter. London: Department of Health; 1998.
  12. RCN. Breast palpation and breast awareness: guidelines for practice in issues in nursing and health. No. 35. London: RCN; 1999.

Resources
Breast Care Campaign
W:www.breastcare.co.uk
RCN Breast Care Nurse Forum
W:www.rcn.org.uk
Cancer BACUP
W:www.cancerbacup.org.uk
Breast Cancer Care
W:www.breastcancercare.org.uk
British Association of Surgical Oncology
Breast Care Group
W:www.baso.org

Study days/conferences
28-30 June 2001
A Journey through Cancer: Nurses Collaborate York
Contact:Adam Berthoud
RCN Conference Unit
E:jointcancer@rcn.org.uk
December 2001
Breast Care Nursing Annual Conference
Harrogate