Case update

It is now 5 years later and Michelle is 50 years old. She remains disease free and is about to be discharged from the follow-up clinic. She will be invited to have a mammography every 3 years as part of the national breast cancer screening programme.

From a medical point of view, Michelle has physically ‘recovered’ from her cancer and its treatment, however she is experiencing a number of chronic effects of treatment. Although Michelle’s cytotoxic therapy did not induce an early menopause, she has experienced hot flushes, vaginal dryness, poor libido and weight gain since commencing tamoxifen.

The surgery has restricted her left arm and shoulder movement which has made carrying bags, swimming and household chores very difficult. Michelle is considering whether she should have a breast reconstruction. She feels that this may have a positive affect on her body image, although she is worried about undergoing further surgery.

The radiotherapy has resulted in dilated blood vessels under the skin around the mastectomy site. This is not painful but, visually, Michelle feels very conscious of this.

Any slight twinge, ache or pain Michelle experiences, she wonders if the cancer has come back. Michelle constantly fears the cancer may reoccur – this is quite debilitating and is a particular problem during the night, affecting her sleep. She is also concerned that the cancer might be linked genetically (even though she has no family history herself), and is anxious that her daughter may be at increased risk of developing breast cancer.

Michelle has been back at work for 4 years and, although she likes the people she works with, she is feeling bored and would like a new job that would stretch her mentally and have more potential to earn more money. She isn’t sure whether she should tell prospective employers about her past medical history and is worried that if she moves jobs she may loss her entitlement to sick leave and pay.

Points to consider

It is incredibly daunting to no longer be seen by the consultant. Patients often express that they feel highly anxious about who will monitor them, in case of recurrent disease, feeling the responsibility of detecting recurrence is on them. For some patients, the fear of recurrence may diminish over time, but for many people, it affects their day-to-day lives. This is just one of the many uncertainties individuals have to deal with after cancer.

The role of the primary care team is paramount in supporting patients once they have been discharged from specialist care in the transition from being ‘a cancer patient’ into ‘normal’ life. However, patients never return to ‘normal’ – their lives are changed forever, whether it is a change of their physical function or appearance or the psychological fear of recurrence or loss of social role and economic status if the individual is unable to return to their pre-cancer employment. The severity and scope of the impact of cancer and its treatment will depend on many variables, but the long-term impact on the individual and their friends and family is enormous. Life will never be the same.

Because historically cancer survival rates have been so poor, there has been a lack of focus on how best to support individuals beyond diagnosis and treatment. With the increasing number of cancer survivors and the chronic nature of the disease, this has begun to change and the National Cancer Survivorship Initiative (Department of Health et al 2010) is focused on possible ways of supporting and prompting self-care in these individuals, as well as the research needed to identify the true extent of the long-term implications of cancer on individuals and society.

Activity

Living with and beyond cancer

What might Michelle’s concerns be regarding being discharged from specialist care completely? What information should Michelle receive on her discharge?

Make a list of what the late effects of breast cancer surgery, radiotherapy, cytotoxic and endocrine therapy might be? What health promotion/education should Michelle receive to stay well in the future?

Find out about the known genetic inherited breast cancer conditions. Explore how knowing about carrying a defected gene that may cause cancer may affect an individual and their blood relatives. What might the ethical issues be relating to this area?

What signs and symptoms of recurrent breast cancer should Michelle be aware of? What might be other signs and symptoms for other types of cancers?

What discussion should healthcare professionals have with Michelle regarding her breast reconstruction? Find out what types of reconstructive surgery there are. What are the risks and the possible cosmetic effects that might result?

Watch the Institute of Medicine ‘Lost in transition’ video on YouTube:

http://www.youtube.com/watch?v=YhuqWM3dNAw (accessed May 2011).

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