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Symptom control for breast cancer

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VOL: 96, ISSUE: 50, PAGE NO: 38

Victoria Harmer, BSc, AKC, RN, is a breast care nurse specialist at St Mary's Hospital, London.

The treatment of breast cancer often involves lengthy and complex procedures that require a high level of holistic nursing care. During cancer treatment patients face a number of challenges, both physically and emotionally, some of which can be ameliorated through the use of the appropriate techniques.

The treatment of breast cancer often involves lengthy and complex procedures that require a high level of holistic nursing care. During cancer treatment patients face a number of challenges, both physically and emotionally, some of which can be ameliorated through the use of the appropriate techniques.

Cancer-related fatigue
Many factors contribute to the severe tiredness experienced by patients undergoing treatment for breast cancer. These include having cancer itself, anaemia resulting from chemotherapy, daily radiotherapy sessions, poor appetite and mental/emotional stress. Fatigue is the most commonly reported symptom of cancer patients, with 78% experiencing fatigue most days, and 73% ranking it as the most debilitating side-effect (Vogelzang et al, 1997).

While further research into the management of cancer-related fatigue is needed, there are treatments available. Blood transfusions and erythropoietin are used to increase the yield of autologous blood in normal individuals and to shorten the period of anaemia in patients receiving platinum-containing chemotherapy.

Corticosteroids and anabolic steroids can also improve fatigue as can counselling (Stone et al, 2000). By talking to patients you can find out why they are feeling an increase in fatigue - sometimes it may be appropriate to provide advice on lifestyle changes and increasing periods of rest.

Lymphoedema
Lymphoedema is a chronic swelling of a limb, resulting from an obstruction to the lymph vessels and flow of lymphatic fluid. Lymphoedema occurs in breast cancer either because there is cancer in the lymph nodes, or because the lymphatic system has been damaged by radiotherapy or surgery (Tiffany, 1988). The result is a swelling of the limb, which causes it to ache and feel heavy and tight.

Sufferers may experience anxiety and depression but, by following a set of simple rules after surgery, they can prevent or reduce lymphoedema. The rules (which patients will need to follow for the rest of their lives) include: not carrying heavy bags with the affected arm; not having blood or blood pressure taken from that arm; always wearing gloves for gardening and washing-up (to prevent infection); and not wet shaving the affected armpit (to avoid cuts that could become infected).

Although there is currently no absolute cure for lymphoedema following treatment for breast cancer, steps can be taken to minimise the problem. These include taking special care of the skin in the affected area to ensure it does not dry out, elevation of the affected arm, the use of compression hosiery, multi-layer bandaging, massage (manual lymphatic drainage), or even surgery. Remedial surgery involves the removal of subcutaneous fat but is carried out only in exceptional cases. It has been suggested that diuretics can be used to combat lymphoedema, although there is as yet little evidence to support this practice.

Clinical spread
Cancer can recur at any time. Recurrence can be local, returning to the same part of the body that was originally affected (i.e. the breast), or secondary (metastases), which occurs when cancer cells have travelled to another part of the body. The status of lymphovascular invasion is an indicator of increased potential for a breast cancer to metastasise. Patients usually die from metastases, not local recurrence (Souhami and Tobias, 1995).

Metastases occur in areas such as the bones, liver, lungs or brain. Cancer cells cause secondary spread by a process that involves cell mobility, detachment, infiltration, dissemination, survival, adhesion and extravasation (Whyte, 1996). The average survival period of metastatic disease after diagnosis is 18-24 months, although this obviously varies greatly between patients. The median time of survival associated with different sites of metastases in patients with breast cancer is shown in Box 1 (Leonard et al, 1995).

The principal site of breast cancer metastases is in the bones. Bone metastases tend to be extremely painful and can result in fractures in the long bones or the collapse of the vertebral column.

Breathlessness may be a symptom of solid intrapulmonary metastases in the lung or a pleural effusion. As shown in Box 1, liver and brain metastases may also occur, and indicate a very poor prognosis (Blamey et al, 1994).

A patient's quality of life obviously becomes of paramount importance once widespread metastases occur. Symptoms can be reduced through the use of analgesia, radiotherapy, chemotherapy and hormones. However, a balance must be made between achieving the control of symptoms and limiting the side-effects of treatment modalities. Treatment plans should include input from palliative care personnel.

Pain relief
A patient's pain needs an accurate description if correct analgesia is to be prescribed, and nurses may find it useful to encourage patients to fill in a 'pain diary'.

It is often only through trial and error that appropriate analgesia can be delivered. If tablets cannot be tolerated, liquid suspensions can be used. If these prove troublesome, suppositories can then be tried. Other options include analgesic patches attached to the skin or subcutaneous pumps. These pumps deliver the required dose of a medication in solution, at a steady rate, through a fine tube and needle under the skin (usually on the abdomen or thigh). Many pumps have a 'bolus button', which means that an extra dose of medication can be delivered if required (known as a breakthrough dose).

A paravertebral block is a local anaesthetic that blocks nerve impulses. This can target specific nerves. Epidurals can also be prescribed. An epidural catheter is placed in the epidural space by a trained anaesthetist to provide analgesia by either continuous infusion or bolus (Buckman, 1997). Other strategies include hot or cold packs, massage, diversion therapy, visualisation, reflexology and meditation.

Fungating breast lesions
Breast cancer is the commonest neoplasm to fungate, a serious side-effect that is the result of tumour infiltration of the epithelium, lymph nodes and blood vessels (Sims and Fitzgerald, 1985). Finlay (1991) provides a vivid description of the physical, psychological and emotional problems of a fungating wound: 'the visible marker of disease that literally eats through the body surface'; 'the patient will be embarrassed by the smell of necrotic tissue, by soiling and oozing from the tumour surface and by the indignity of having a sensitive part of the body destroyed'.

Moist areas of necrotic tissue can lead to bacterial infection and odours. It is therefore important to use the correct dressing for these fungating wounds. Swabs should also be taken and topical metronidazole gel used for odour control. Charcoal dressings can also reduce the odour.

If the wound has a heavy exudate, alginates would be a good choice plus a secondary absorbent dressing. Drainage bags could also be used.

For wounds that are prone to bleeding, the alginate dressing should be soaked off. Tranexamic acid soaks, which promote coagulation, can also be used to control bleeding. If the surrounding skin is itchy, hydrogel sheets could be applied to cool it.

Fungating wounds cause severe psychological distress to patients. Not only could the presence of this wound bring social isolation, but also the size of the dressing required and the problem of exudate containment may add to body image problems, and deem certain clothes unwearable. Nurses can help by ensuring the patient has access to supportive care and advice.

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