Local Therapy

for Breast Cancer: Treatment Decision Making

Choices and

Barbara Hansen Kalinowski

R

for local treatment of ECOMMENDATIONS early-stage (stages I and II) breast cancer have changed significantly since the 1985 issue of Seminars in Oncology Nursing that featured breast cancer. At that time, mastectomy was still considered the standard treatment for breast cancer. Although it was considered promising, breastconserving surgery was still experimental because the long-term results had not yet been reported. This article will update the readers on the current local treatment options for breast cancer. The article will focus on the surgical and radiotherapy treatment changes that have occurred over the past 5 years and will discuss how choices for treatment may be presented to women and what nurses need to know to help support women who are at the point of choosing local therapy for breast cancer. BREAST CANCER: A LOCAL AND SYSTEMIC DISEASE

The treatments for breast cancer have changed because we have changed our way of thinking. Previously, the malignancy was believed to start in the breast, get slowly bigger, and then move one by one up the lymph nodes in the axilla and out to the rest of the body. Having surgery quickly was important, and the surgery that was done was radical. We now know that most cancers have probably been present for 8 to 10 years before diagnosis’ and have metastasized microscopically by the time of diagnosis. If there is a high chance of distant metastases at the time of initial diagnosis (ie, a large tumor, or inflammatory cancer), then systemic therapy (chemotherapy or hormonal therapy) will be done before local treatment. Local treatment of the breast is a secondary issue. Women do not die of cancer in their breast, but from breast cancer that has metastasized to vital organs.* The goal of local therapy for early-stage breast cancer is local control--elimination of the cancer in the breast with the thought that micrometastases that may be present in the rest of the body will be eliminated by the individual’s immune system or by adjuvant chemotherapy or hormonal therapy. Local therapy helps to prevent cancer from Seminars

in Oncology

Nursing,

Vol 7. No 3 (August),

1991:

pp 187.193

recurring in the breast. This involves either mastectomy or removal of the lump followed by a course of radiation therapy. LOCAL TREATMENT

OPTIONS

The National Cancer Institute and the Office of Medical Applications of Research of the National Institutes of Health convened a Consensus Development Conference on the Treatment of EarlyStage Breast Cancer in June of 1990.3 The goal of this group of national experts was to evaluate research in the field of breast cancer and to provide direction to researchers and clinicians regarding approaches to breast cancer treatment. The first two questions asked by the panel addressed (1) the role of mastectomy versus breast conservation in the treatment of early-stage breast cancer and (2) the optimal techniques for breast conservation. After considering data from prospective trials with 17 years of follow-up, and with discussion of patient selection criteria and recommendations for surgical technique and for optimal radiation therapy, the following statement was issued: Breast conservation treatment (excision of the primary tumor plus radiation therapy) is an appropriate method of primary therapy for the majority of women with stage I or II breast cancer, and is preferable because it provides survival equivalent to total mastectomy and axillary dissection and also preserves the breast.?

As a result, physicians who in the past were hesitant to present the two treatment options as equal should now feel more comfortable with the consensus statement fully supporting the choice. Women faced with these choices can also be reassured by the careful deliberation of national experts and their subsequent recommendations. There are some circumstances in which breast conservation is not the optimal treatment, and mas--From the Faulkner Breast Centre, Boston, MA. Barbara Hansen Kalinowski, MSN. RN, OCN: Clinical Nurse Specialist, Faulkner Breast Centre. Address reprint requests to Barbara H. Kalinowski, RN, Faulkner Breast Centre. 1153 Centre St. Boston. MA 02130. Copyright 0 1991 by W.B. Saunders Companv 0749-20~119110703-0006$S.O0

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BARBARA

108

tectomy is suggested.The factors that lead to this recommendationare listed in Table 1. Mastectomy would be recommendedif removing the breast tumor would leave the woman with a cosmetically unacceptablebreast. If extensive intraductal carcinoma (EIC) is present at the margin of the specimen (often after several attemptshave been made to surgically remove the EIC by wide excision), recommendation for mastectomy will be made both becauseof the increased chance of local recurrence, and the unacceptablecosmetic result of repeatedwide excisions.4V5If breast cancer recurs locally (in the breast itself) and the woman has had previous breast-conserving surgery and radiation therapy, mastectomy would be recommended as the most effective local treatment becausebreast tissue can ony be radiated once. If there is local recurrencewithout distant metastases, the ultimate prognosis is not affected.6 The algorithm shown in Fig 1 outlines the choices available for the treatment of early-stage breast cancer when a woman is an acceptablecandidate for either mastectomy or breast conservation. For example, after tissue diagnosis and staging, a woman may chooseto have a wide excision (also called a partial mastectomy) or a mastectomy, with or without immediate reconstruction. In either case, an axillary dissection is recommended to provide prognostic information and for decisions regarding systemic therapy. In addition to very different cosmetic results, the two choices for local therapy also require very different amounts of time for their completion, duration of hospital stay, and amount of interaction with health care personnel. Women who have breastconserving surgery usually have brief hospitalizations, and the surgical procedure is often done in the outpatient setting.7 They may or may not have

Table 1. Criteria

Used to Recommend

Mastectomy

Tumor/breast size ratio: When removal of the tumor alone would leave a cosmetically unacceptable result. EIC present at margins: Extensive intraductal carcinoma present at the margins of the tumor resected. Multiple tumors: Several tumors, especially in different areas of the breast. Previous breast irradiation: For local recurrence, mastectomy considered a salvage procedure. History of severe asthma or emphysema (lung capacity diminished): Radiation therapy contraindicated because of possible effect on already compromised lung tissue.

HANSEN

KALINOWSKI

a drain placed in the axilla, and generally need little in the way of skilled nursing care for their immediate postoperative recovery. Several weeks after surgery, daily radiation therapy begins and lasts for about 6 weeks. It is often during radiation therapy that women turn to nursesfor support and information. Women who elect mastectomyhave a hospital stay that usually lasts from 4 to 7 days, depending on the institution, the procedure, and the physical health of the woman. Nursesfind they can be extremely helpful during this time to help sort out feelings, answer questions, and facilitate both emotional and physical healing. Nurses need to have a clear understanding of the pathologic types of breastcancer(Table 2) and their treatment options in order to help interpret the sometimes confusing information the woman may receive. TREATMENT OF NONINVASIVE

CARCINOMA

Ductal Carcinoma In Situ Ductal carcinoma in situ (DCIS) may present in a variety of ways,’ and local therapy recommendations are largely basedon the size of the lesion. DCIS picked up by mammogrammay be marked by microcalcifications that are linear in appearance or in a cluster or groups. A needle localization biopsy is done to remove the microcalcifications that are not palpable or visible except on mammogram (seearticle by HasseyDow elsewherein this issue). DCIS may also present with unilateral bloody discharge or, rarely, a massor lump. Treatment options for DCIS are controversial and range from wide excision to mastectomy.’ Generally, guidelines for treatment are those shown in Fig 1. Becausethis lesion does not have the capacity to spread to organs outside of the breast, the stagingtestsare not usually done before definitive treatment, and axillary node dissections may not be required except in the case of lesions larger than 5 cm in diameter.” These recommendations may be different across the country and may changeas knowledge of the natural history of DCIS increases through research from national clinical trials. To date, however, the woman diagnosed with DCIS may be both relieved with the potential for cure and confused about the choices for optimal therapy. Lobular Carcinoma In Situ Lobular carcinoma in situ (LCIS) is usually found incidentally at the time of a biopsy for some

LOCAL THERAPY

FOR BREAST

CANCER

189

Diagnosis: Fine-needle aspiration, incisional biopsy, excisional biopsy

T Staging: Bone scan, CXR, liver function tests, CEA

I t

I

Axillary dissection Wide excision

*

Dirty margins

I

9

Clean margins

Fig 1.

Local treatment

choices

for women

with

eerly-stage

other breastcondition. LCIS cannot be detectedby physical exam becauseof its microscopic diffuse nature or by mammography as it does not form a mass and is not usually marked by calcifications. LCIS is considered not a true cancer but a marker or a factor that puts one at risk for developmentof an invasive breastcancer. Usually, LCIS is present in both breasts. If a woman who has LCIS does develop invasive breast cancer, it is not always in the breastin which the LCIS was originally found, and its pathologic type is usually invasive ductalrarely invasive lobular. i” Although bilateral mastectomies are occasionally recommended, a less drastic approach basedon available data is to recommend women have regular physical exams (every 3 to 4 months) by an expert practitioner and routine mammography based on the American Cancer Society guidelines. TREATMENT

OF INVASIVE BREAST CANCER

Local therapy options and the changesthat have occurred over time are listed in Table 3. Generally,

breast cancer.

CXR, chest x-ray;

CEA, cercinoembryonic

antigen.

mastectomy is a procedure that removes all the breast tissue and the nipple/areolar complex, but carefully preserves surrounding nerves and chest wall muscles. Breast-conserving surgery removes the breasttumor and a rim of normal breasttissue. The specimenshould be carefully evaluatedby the pathologist to ensure no presenceof breast cancer at the margin. The surgery is followed by 6 weeks of radiation therapy. The total dose of radiation therapy has been decreasedfrom that prescribed 5 years ago, with improved cosmetic results. The use of interstitial breast implants requiring hospitalization is not routinely done. CHOICES DURING A CRISIS

A woman facing the diagnosis of breast cancer in the 1990s is affected by a variety of stressors, both psychologic and physical. Many of the issues a woman must consider when dealing with breast cancer today are quite different from those that confronted a woman diagnosed 5 or 10 years ago (Table 4). It is possible that the crisis or point of

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BARBARA

Table 2. Patholoalc

Twee

of Breast Cancer

Noninvasive (or in situ or precancer) l Confined to its site. l Lacks potential to spread to other parts of the body. Ductal (or Intraductal, DCIS) l Malignant cells of ductal origin that are contained in the duct. 0 Often presents as microcalcifications on mammogram, or with bloody nipple discharge. 0 Rarely presents as a lump. Lobular (LCIS) l Abnormal cells of lobular origin that are contained within the lobule of the breast. l Usually bilateral and multicentric. l Not visible on mammogram, and does not present as a palpable mass. l Often diagnosed incidentally at the time of a biopsy for other reasons. Invasive (or infiltrating) l Invasive capacity outside cells of origin. l Potential to spread from the breast through the blood vessels (primarily) and lymphatics to other organs. l General category of breast cancer is adenocarcinoma. Specific types are: Ductal l Malignant cells of breast duct origin have broken through the walls of the duct and are now found in the surrounding breast tissue and fat. l Most common type of invasive breast cancer (about 70% to 80% of all breast cancer). l Usually presents as a solid mass, may have a spiculated (star-shaped) appearance on mammogram. Lobular l Malignant cells of breast lobule origin are now invading into the surrounding breast tissue and fat. l Comprises about 5% of breast cancer. l May present as a large, lumpy area, a thickening, or with a large lump. Combinations 0 Often combinations of cell types (invasive, both ductal and lobular, as well as noninvasive) present in the breast tumor. l Less common types of breast cancer include: medullary, mutinous, tubular, papillary and inflammatory.

highest anxiety that occurs in the beginning phases of the experience of breast cancer has shifted over time. Women now have several options for local and systemictherapy and can play an active part in choosing the course of their care. Historically, a one-stage procedure (biopsy and mastectomy in one procedure) did not allow time to think about the cancer diagnosis, to mobilize supports, or to adjust to the thought of physical change before major body-altering surgery was performed. Today, the majority of women who suspect breast

HANSEN

KALINOWSKI

cancer begin to gather information by either reading lay or professionalpublications, or by speaking with others who have experiencedthe diseaseand may identify supports before definitive treatment begins. Most health care professionals who interact with women facing the diagnosis of breastcancer are attuned to the variety of responseswomen have to the diagnosis, as well as the different coping styles exhibited by women during this intense situation. It is during this emotional upheaval that women are askedto consider an enormousamount of information, learn a new language, and make decisions that will impact their life. COMPARING THE IMPACTS OF BREAST-CONSERVING SURGERY AND MASTECTOMY

Much researchhas been done to assessthe impact of breastsurgery on women’s lives. Somehas beenretrospective, comparing reactions of women who had mastectomy versus breast-conserving surgery’ ’ ; others compare women who have not chosen the surgical procedure but have been randomly assignedto various treatments.I2 Much has beenlearnedfrom responsesof women after breast surgery.l3 Psychologic and physical aspectsof life have been reported as being affected after breast surgery, including self-image, sexuality, relationships with significant others, energy levels, and mobility. l4 The research that compares breastconserving surgery with mastectomy should help us answer the question, “How do women choose the kind of surgery that is best for them?” Choice as a Factor Little research has examined how women choose the type of local therapy for themselves. Rowland and Holland15 summarize 10 small studies that look at responsesof women who have chosen mastectomy versus breast conservation and find that women with breast conservation show better overall adjustment. However, Levy et all6 show no difference or more distress in the breast conservation group with a follow-up time of 3 months. Two points may be gleanedfrom many of these articles and are important for the health care professionals working with women with breast cancer. First, women who feel they have a choice (whether it is betweenmastectomyand breastconservation, reconstruction or not, or no therapy at

LOCAL THERAPY

FOR BREAST

CANCER

191

Table 3. Thraoies

radical

mastectomy

Breast-conserving surgery (may be called partial mastectomy or wide excision)

Adjuvant

radiation

therapy

Full treatment takes 6 to 6% weeks. Daily treatments to whole breast for 4% to 5 weeks. Total dose of 4,500 to 5,000 cGy to the whole breast. Boost to the tumor bed with electron beams (1,600 cGy over 8 days) or with interstitial implants @day hospitalization) for a dose of about 1,500 to 2,000 cGy.

Table 4. Changes in the Psychologic Issues in Primary Breast Cancer Treatment: Past and Present Past: 15 to 20 Years Ago

Minimal social support or special rehabilitative programs

Reprinted

Changes

Removal of all breast tissue, nippleiareola complex, level I and II axillary lymph node dissection. Often accompanied by immediate breast reconstruction. Removal of the tumor with a rim of normal tissue surrounding it (negative margins), level I and II axillary dissection (usually removes between 5 and 15 lymph nodes).

all with close observation) and are given adequate information and enough time, adjust or adapt well.‘5 Secondly, women who are psychologically healthy before the diagnosis of breast cancer usually manageto remain that way after the diagnosis

Fears of breast cancer and mastectomy One-stage biopsy with or without mastectomy under anesthesia Little participation in treatment decision Little or no discussion of survival or prognosis Full reassurance about future; minimal follow-up

of Breast Cancer

Current Practice

Theraw Modified

for Local Control

Present Fears of breast cancer and choice of treatment options Knowledge of two-stage procedure and two treatment options (mandated by law in some states) Full participation in care and choices made by patient Full disclosure of survival prognosis

Limited emphasis on reassurance about future; emphasis on frequent and long-term observation Access to self-help and support groups; availability of breast reconstruction; information that node-negative women should receive chemotherapy or hormone therapy

with permission.‘s

Halstead radical mastectomy (wide skin excision, all breast tissue, pectoralis major and minor, full axillary dissection) is rarely done today. Quadrantectomy (removal of one quadrant of the breast) usually not done; often leaves large cosmetic defect. Axillary dissection done for prognosis and to avoid axillary irradiation. Attention to margins important: increased risk of local recurrence with grossly involved margins. Total dose decreased from 6,000 cGy to between 4,500 and 5,000 cGy to the whole breast. Found to be as effective with improved cosmesis (less breast retraction and fibrosis). Boost more likely to be with electron beam than implant.

and tolerate either mastectomyor breast conservation therapy well. i’ Much of the literature that attempts to look at the impact of breast cancer does so in a short time span, usually 6 weeks to 3 months after diagnosis. Clinical experience shows that few women have adapted to the impact of breast cancer on their lives in that short a time period, and thus may not be reporting their longterm reactions to their choices of local therapy. A more accurateportrayal of responseto the choice may take as much as 5 years after treatment.l8 It is also difficult to determine whether the anxiety or distress reported in various studies is actually a result of the choice of local therapy or of the cancer diagnosis, regardlessof treatment. The issue may not be the choice of therapy, but the effect breast cancer has on one’s life. As one woman so eloquently expressedit, “My grief was not becauseI lost a breast, but becauseI have had breast cancer-1 have been transformed--I’ll never be able to not have breast cancer. I grieve for the loss of the ‘old’ me.” Other Factors in Decision Making

Nursesneedto be awareof the variables that are important to assessin women who are diagnosed with breastcancerand who are choosing therapies. They also need to identify how they can function as supports and advocatesfor women in these cir-

192

cumstances.Both external and internal factors affect the woman’s decisions about treatment for breast cancer. Valanis and Rumpler” report four frequently mentioned influences on decision making. The first is the media, especially television and magazinesand media coverage of breast cancer experiencesof prominent women. Second, the physician influences the decision making process. The physician will review options for treatment with the woman and, basedon pathologic findings and size of the tumor in relation to the breast, will present the choices outlined in the treatment algorithm (Fig 1). The third factor is the effect of family, significant others, and friends on the woman making decisions. Finally, they list individual coping styles, past experience with similar crises, and self-image as having some influence on decision making. l9 The physician’s assessmentbased on the knowledge of the patient through past history or the experience the physician has gained by past interactions with other patients may also impact on the options presentedto the patient. Prior experience may include perceptions of ability to cope, physical stamina, social support, and explicit desires of the woman, such as “You tell me what to do, I can’t decide,” or “Just do it soon, I can’t stand waiting.” The physician influence may be helpful or detrimental, especially if there is a paternalistic physician-patient relationship (eg, “If you were my wife. . . . “). Valanis and Rumpler19 report that a contractual or consumer-oriented model of communication encouragesparticipation of the patient and family in decisions. Ward et a12’ report several factors that women consideredwhen choosing between mastectomy and breastconserving surgery: fear of recurrence, survival rates, fear of radiation therapy, concern for body integrity, and physician preference. The authors comment that clinical expertise is essential in presenting options to support women in the decisionmaking process. Interaction with a nurse or other supportive health care professional at this point may be cruciaL2’ Assessmentsof individual characteristics related to the breast cancer diagnosis can be a particularly useful exercisefor both the patient and the professional staff in helping to clarify perceptions of the event, identify and mobilize coping mechanisms, and begin the processof adaptation or adjustment to living with breast cancer. The patient may relate past experiencesof relatives dying of breastcancer and the fear that shemay have

BARBARA

Table 5. Nursing Interventions Decisions About

HANSEN

KALINOWSKI

to Support Women Local Therapy

Making

Clarify information Test results Pathology reports Treatment options Coordinate family meetings with appropriate health care professionals Act as an outsider, an impartial sounding board to help with the decision-making process Provide information about resources for support Support groups Individual therapists Individual patient networks (personal visits or by telephone) Provide teaching about preoperative and postoperative concerns Reconstruction (show slides, videos) Show and encourage handling of prosthesis and mastectomy bras Discuss surgical and postoperative limitations Discuss issues of work, insurance,

routines,

mobility

and follow-up

care

for her own course of the illness. The nurse can listen, question, and provide reassuranceto help the patient place herself in a more realistic framework within her past history. The nurse may also hear misconceptionsabout therapy (eg, fear of the effects of radiation therapy) and be able to encourage consultation with specialists to help provide current information during this time of decision making. Table 5 lists some of the actions nurses can take to support women during the period between diagnosis of breast cancer and making the decision for local therapy. Oncology nursesneed to understandthe current treatment options available to women who are diagnosedwith breast cancer and how these options have changed over time. Thus, we must have a good understanding of the biologic behavior of breast cancer, prognostic factors, pathology, and current recommendations for therapy. Oncology nurses are in a particularly important position to provide correct therapeutic information, assessthe impact of the diagnosis of breast cancer on the woman and her supports, and provide psychologic and educational support during this time of crisis. ACKNOWLEDGMENT The author thanks Judi Hirshfield-Bartek, RN, and Drs Susan Love, Kathy Mayzel, and Claire Carman for reading and commenting on this manuscript.

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CANCER

REFERENCES 1. Fisher B, Redmond CB, Fisher E, et al: Ten-year results of randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. N Engl J Med 312:674-681, 1985 2. McKhann C: The changing role of surgery in the treatment of breast cancer. Semin Oncol Nurs 1:176-180, 1985 3. Treatment of Early-Stage Breast Cancer: Nat Inst Health Consensus Dev Conf Consensus Statement, June 18-21, 1990,

S(6) 4. Osteen R, Connolly J, Recht A, et al: Identification of patients at high risk for local recurrence after conservative surgery and radiation therapy for stage I or II breast cancer. Arch Surg 122:1248-1252, 1987 5. Holland R, Connolly I, Gelman R, et al: The presence of an extensive intraductal component following a limited excision correlates with prominent residual disease in the remainder of the breast. J Clin Oncol 8:113-l 18, 1990 6. Recht A, Schnitt S, Connolly J, et al: Prognosis following local or regional recurrence after conservative surgery and radiotherapy for early stage breast carcinoma. Int J Radiat Oncol Biol Phys 16:3-9, 1989 7. Siegel B, Mayzel K, Love S: Level I and II axillary dissection in the treatment of early-stage breast cancer. Arch Surg 125:1144-1147, 1990 8. Rosen P: The pathology of breast carcinoma, in Harris J, Hellman S, Henderson IC, Kinne D (eds): Breast Diseases. Philadelphia, PA, Lippincott, 1987, pp 147-209 9. Gump F: In situ cancers, in Harris J, Hellman S, Henderson IC, Kinne D (eds): Breast Diseases. Philadelphia, PA, Lippincott, 1987, pp 359-368 10. Recht A, Connolly J, Schnitt S, et al: Therapy of in situ cancer. Hematol Oncol Clin North Am 3:691-708, 1989

11. Holmberg L, Omne-Ponten M, Bums T. et al: Psychosocial adjustment after mastectomy and breast-conserving treatment. Cancer 64:969-974, 1989 12. Fallowfield L, Baum M, Maguire G: Effects of breast conservation on psychological morbidity associated with diagnosis and treatment of early breast cancer. Br Med J 293: 133 l1334, 1986 13. Wolberg W, Romsaas E, Tanner M, et al: Psychosexual adaptation to breast cancer surgery. Cancer 63: 1645- 1655, 1989 14. Psychological Aspects of Breast Cancer Study Group: Psychological response to mastectomy. Cancer 59: 189-196, 1987 15. Rowland J, Holland J: Breast cancer, in Rowland J and Holland J (eds): Handbook of Psychooncology. New York: Oxford University Press, 1990, pp 188-207 16. Levy S, Herberman R, Lee J, et al: Breast conservation versus mastectomy: Distress sequelae as a function of choice. J Clin Oncol 7:367-375, 1989 17. Sinsheimer L, Holland .I: Psychological issues in breast cancer. Semin Oncol 14:75-82, 1987 18. Vinokur A, Threatt B, Vinokur-Kaplan D, et al: The process of recovery from breast cancer for younger and older patients. Cancer 65:1242-1254, 1990 19. Valanis B, Rumpler C: Helping women to choose breast cancer treatment alternatives. Cancer Nurs 8: 167- 175, 1985 20. Ward S, Heidrich S, Wolberg W: Factors women take into account when deciding upon type of surgery for breast cancer. Cancer Nurs 12:344-35 1, 1989 21. Hill H: Radiation or mastectomy: A choice for living. J Psychoscc Oncol 4:77-90, 1986

Local therapy for breast cancer: treatment choices and decision making.

Treatment options for the woman diagnosed with breast cancer have changed considerably over time. Mastectomy was standard treatment for breast cancer ...
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