Psychosocial Impact of Breast Surgery

CHAPTER 1: INTRODUCTION

This chapter introduces the topic of the systematic study, which is the psycho social impact of breast cancer surgery on patients and their family members. The chapter will give a detailed introduction by looking at the rationale of the study. This will extend to the research question on the psycho social impacts of breast cancer surgery on patients and their family members, which in this case will guide the entire study. The last item in this chapter will be stating the research objectives, all which are defined or rather guided by the earlier defined research question. The research objectives will provide an explicit statement of the psycho social impacts of breast cancer surgery on patients and their family members, with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).

1.1 Rationale

Exceptional developments have been realized, not only in the treatment but also the aftercare offered for breast cancer by medical professionals. Despite the above-mentioned advanced, a good number of women are still subjected to significant issues that are both psychological and sociological in nature. This comes at the time when receiving care as well after going through the treatment plan. Among the commonly reported concerns for the female patients following a breast cancer surgical treatments are the feelings of stigma and isolation and concerns related to body image. Other issues include lack of information with regard to the extent and the right kind of care visits that the post-surgical patient should consider. Perhaps, the above argument forms part of the recommendations by Denford, Harcourt, Rubin and Pusic (2011) on the need to come up with ways that will help in addressing the problems in order to realize the best outcome for post-surgical patients, as a whole. Gopie et al, (2014) argues that underlying some of the relevant issues that can create room for emotional and psychological difficulties for women can see relevant players in the healthcare field efficiently utilize the available resources in the recovery and treatment path. The above assertions are confirmed by Boquiren et al., (2016), postulating that well-defined line of communication are essential in seeing that an optimal care is accorded for patients reported with breast cancer. This entails seeing that patients enjoy a readily available access to updated information with regard to their treatment plan. Also, this should extend to seeing that these patients can take part in an online as well as in-person support structures and system, in order to come up with an environment that is highly conducive, not only for healing but recovery as well. Studies by Shannon (2015) have confirmed that breast cancer has proved to be particularly difficult, and mostly for younger women in the society. The effects are felt by other women lacking the necessary built external social support networks; away from their home. Just as Matthews et al., (2017) have put it, the adolescents and young adults require the necessary additional help which will see them cope with issues that come with breast cancer as well as its treatments. There are a number of options through which healthcare professionals can offers a healing experience that is quite effective, to the younger women. Among the approaches may include paying attention on both physical and psychological aspects of the conditions on the vulnerable individuals. On that note, this paper seeks to come up with a systematic review on the psycho social impacts of breast cancer surgery on patients and their family members.

1.2 Research Question and Objectives

Basing on the already introduced rationale for the study, the systematic review aims at exploring the following research question:

“What are the psycho social impacts of breast cancer surgery on patients and their family members?”

As per the above formulated research question, the objectives of the systematic review will entail:

To explore the existence and prevalence of psycho-social impacts of breast cancer surgery among patients undergoing breast cancer treatment. To investigate the psycho-social impacts of change body image among breast cancer patients undergoing surgery treatment. To explore the psycho-social impacts of breast cancer surgery on patients undergoing breast cancer treatment

CHAPTER 2: METHODOLOGY

The current chapter entails a detailed discussion and illustration of the search strategy that were embraced during the process of gathering evidence for the current literature review. By doing so, the chapter will undertake a detailed analysis of the databases that were utilized during the process of undertaking the research for literature and the process as well as mechanism adopted in formulating the research question. Also, the research will look at the tools that were used in gathering the relevant data and information guiding the literature review. Most importantly, the chapter will come up with a detailed discussion on the criteria used for inclusion and exclusion, in addition to the rationale guiding the same.

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2.1 Search Strategy

While defining a search strategy, the works of Blumenthal-Barby and Krieger (2015) refer to an organized structure of key terms that are adopted in during the process of searching for a database. A similar framework took a center stage in the current literature review, where a systematic research and analysis was adopted for the same. A systematic process was embraced while searching for information and gathering evidence in relation to the psycho social impacts of breast cancer surgery on patients and their family members. Through this approach, the study was well placed to analyze the findings as well as established a highly comprehensive summary. In order to realize the objective under this section and the entire study as a whole, the research study accounted for the entire possible search terms that would guide towards exploration of the defined title. This extended to the keywords and phrases, which would guide on relevant information pertaining post-surgical stress for female cancer patients. The research further looked on the possible changes in search terms, where some might have been truncated. Similarly, the research strategy took into account the relevant subject headings. Just as Gopie et al., (2016) puts it, the respective data bases function differently, thus the need for adapting the search strategy for each. Taking of the above information, the gathered evidence was used in evaluating how effective the entire literature was, in addition to how it can best offer evidence that offer support or rather is in line with the psycho social impacts of breast cancer surgery on patients and their family members. Furthermore, the process was defined in a systematic manner at least to pave way for transparency as well as duplication of study outcomes. Generally, the approach saw the systematic process of literature creating room for further insight to the psycho social impacts of breast cancer surgery on patients and their family members.

2.2 Data Bases

In the process of conducting a literature search, the study embraced the electronic option by utilizing the relevant databases and search engines. The approach was guided by the fact that the use of online databases creates room for the make the search simply by keying in specific words that were in line with the psycho social impacts of breast cancer surgery on patients and their family members; the research question. Going this way, the search was simplified as compared to the case of books and other material resources available in the library. To a greater extent, the process proved that it could be easily followed as well as replicable. The study explored a number of data bases that would offer relevant information pertaining breast cancer surgery. These ranged from the Medical Literature Analysis and Retrieval System On line, commonly termed as MEDLINE and PsycINFO. Other relevant data bases used in retrieving the relevant information include the Cumulative Index to Nursing and Allied Health Literature, commonly known as CINAHL and the famous Google Scholar. Also, the study took advantage of the vast body of knowledge and information available in the ProQuest Library. The use of the above-mentioned data bases was directed by the fact that they are all relevant on matters to do with medicine and nursing. Furthermore, they compiled a vast body of literature, which in this case prove to be quite fundamental to the nursing field.

2.3 Search Items

A number of search terms were used for the purposes of retrieving relevant information pertaining to research question or interest: the psycho social impacts of breast cancer surgery on patients and their family members. Among the terms included cognitive behavioral therapy, management of cancer pain or pain-related cancer, pharmacological and non- pharmacological interventions, sociological and physiological interventions. Other relevant terms that took a center stage during the search included adult female cancer patients, alternative therapies and cancer pain among others. The above-mentioned terms were selected for the purposes of a detailed comprehensive search for the current literature on the defined research question and objectives. In order to suit the respective databases, the research questions had to be customized. The same approach was developed in order to be in line with the various combinations of terms used for Medical Subject Headings (MeSH). In order to realize the goals under this chapter, the study had to make use of the free words searches. With this kind of tools in place, the chosen key terms were easily linked to a number of the anticipated medical heading in the respective databases. Furthermore, a manual search had to be undertaken by going through the list of articles that were eligible enough as well as relevant reviews. The reason behind going this route was to come up with articles that were not only applicable but suitable as well to the psycho social impacts of breast cancer surgery on patients and their family members.

2.4 Research Question Formulation

In order to come up with the already defined research question, the study employed the Population Exposure Outcome (PEO) approach. Just as Denford et al (2012) have put it, the approach is commonly adopted in the healthcare field; largely thanks to the fact that it facilitates the identification of key terms and concepts that are relevant in the pre-defined research question. Also, the approach facilitates the process of coming up with the most appropriate and suitable search terms while illustrating the same. With this kind of strategy tool in position, it becomes easier to come up with the inclusion and exclusion criteria, as evidenced in the current systematic review of literature. Talking of population, Buki et al (2016) refers to the targeted individuals under the planned study. The same applies in this case, where the targeted population was adult female patients, who were subjected to the pain related to breast cancer. On the other hand, exposure basically entails the kind of intervention adopted in the study. Similarly, the concept extends to the given area of interest. Basing on the defined question and research objectives, the exposure in the current study was Cognitive Behavioral Therapy. While defining the outcome in a scientific study of this nature, the works of Buki et al (2016) refer to the experiences undergone by the patient as well as the desired effect. The above definition fully applies in the current study, where the desired effect is an enhanced or rather better quality of life as well as minimized pain or experiencing zero pain for female adult patients who have gone through breast cancer operations. A number of alternative key words for the PEO were brought into play, with some of them truncated for the purposes of facilitating the alternative endings to the terms. A good example is the case of Nurs*, which can come up with searches with a number of word endings such as nurse, nurse and nursing, among others. In this case, the fundamental question was the effectiveness of Cognitive Behavioral Therapy when adopted as an intervention for managing post-surgical pain for breast cancer female adult patients.

The table below provides an illustration of the research question formulation by use of the PEO:

2.5 Boolean Operators

The study made use of Boolean operators in organizing as well as arranging the search terms. These were OR and AND which facilitated the process of terms combination and creating room for precision with regard to come up with required information. Also, it paved way for high levels of specificity, which came alongside sensitivity of the used searches. A good example is the case of OR, which plays the relevant role of broadening the search through inclusion of information that are either similar or connected to one another. On the other hand, AND was useful for narrowing the search through combination of the relevant words and search terms. The table below provides a summary of the keywords used in the search terms:

2.6 Inclusion and Exclusion Criteria

The works of Denford, Harcourt, Rubin and Pusic (2011) have put it clear that inclusion and exclusion criteria provides a detailed illustration if the scope as well as how relevant the literature being researched is. The same applies in the current dissertation where the research was limited only to previous studied done in English; all trying to address the psycho social impacts of breast cancer surgery on patients and their family members. The above-stated limitation was directed by the need to enhance data understanding, followed by an interpretation in a more accurate manner. This is based on the fact that nursing practice is one of the most evolving fields, characterized with technological advancement as well as a detailed comprehension of the human body. In that line, the study considered literature from the year 2003 going back as less updated and lacking the necessary validity. Furthermore, the literature evidence gathered in the study had to take care of the full text and the corresponding abstracts in order to come up with highly comprehensive literature reviews and corresponding analysis. Most importantly, the search was quite limited to female adult patients who had been diagnosed with breast cancer, since this proved to be quite relevant to this particular area of nursing. The table below provides a summary of the same:

2.7 Data Extraction

From the identified peer reviewed articles, the process of data extraction was undertaken in a more independent way. For the respective study under each article, the research gathered the following information:

All names of the first or initial author. The region and setting of the study area. The year when the study or assessment was undertaken. The age range of the participants who took part in the study. The size and demographic characteristic of the sample. The method(s) of data collection used in the study. The main findings following data analysis and interpretation.

2.8 PRISMA Tool

The following is the PRISMA tool providing an illustration of the article research proces

2.8 Critical Appraisal

Among the critical components of any literature review is the critical appraisal of the gathered literature. Buki, Reich and Lehardy (2016) argue that going this route helps in determining the quality of the gathered evidence. Furthermore, the approach paves way for the identification of relevant information that had been presented and their relevance in addressing the research question. The relevance extends to the healthcare in practice. The approach entails a detailed measuring or rather computation of the strengths and weaknesses that show up in a particular scholarly work, and if by any chance it is of any relevance to the research question. A number of frameworks have been adopted in realizing the same, with the major one being the Critical Appraisal Skills Program, commonly termed as (CASP). The CASP framework looks into important elements of the gathered evidence, among them including their credibility, relevance and rigor. Also, the framework offers a checklist that comes with 10 questions, all which are broken into three major sections. The first section entails finding out if the study results are valid or not. The second section entails finding out or rather defining the results. The last section is all about establishing if the study outcomes will be used locally. With this kind of tool in place, healthcare professionals are better placed when it comes to developing a detailed understanding of the presented literature. The approach, in turn paves way for an enhanced evidence-based practice in the entire field of healthcare.

2.9 Summary

In summary, the selected databases in the current study were subjected to systematic searching, just as defined in the introductory section of this chapter. Key terms were effectively used, with each proving to be relevant to the already defined research question, whose formulation was undertaken as per the PEO tool. This was followed by a critical appraisal of the selected peer reviewed articles by use of the CASP tool to see that the study settled for the literature of good quality.

CHAPTER 3: RESULTS

3.1 Study Characteristics

In the article Women's Educational Needs and Perceptions About Survivorship Following Bilateral Mastectomy, Boiler aimed at exploring the educational needs and perceptions held by women with regard to survivorship after going through mastectomy. In this case, mastectomy was considered as one of the best way of treating unilateral breast cancer. The study entailed an exploratory qualitative approach, going for women of age 18 and above as the inclusion criteria. All the women had good command of English and had been diagnosed with unilateral breast cancer. Up to 23 women took part in the study, with only one an African American, and the rest Caucasian. Their average ages were 44 years, with a mean diagnosis timeline of 2.5 years. 20 of them were married, 19 employed and 20 with private insurance. They all had some college education, with almost 12 reported as graduates. The table below provides the women’s tumor characteristics:

The works of Matthews et al on Predictors of satisfaction and quality of life following post‐mastectomy breast reconstruction, examined some of the factors that give prediction on satisfaction reported by patients of post-mastectomy breast reconstruction. The criteria for study eligibility entailed breast cancer patients who were undergoing reconstruction of the same. The entire participants were of age 18 and above, with no palliative treatment. The eligibility criteria saw 263 women aligned for the same. They all are responded to the study questions under the use of postal questionnaires, which came alongside the consent form. The table below provides the demographic and clinical characteristics of the sample:

Studies by Buki, Reich and Lehardy (2016) on Our organs have a purpose: body image acceptance in Latina breast cancer survivors, looked into the body image concerns raised by breast cancer survivors among the Latina white women. Study participants were 27 Latina who had survived from breast cancer, all aged between 35-68 years. The population sample was made up of immigrants from different regions into Latin America, among them including South Merico, Mexico and Puerto Rico. At least 67 had gone through formal education for 12 years, 59% married, while the remaining divorced or widowed. The works of Shannon, I Was Trapped at Home: Men's Experiences with Leisure While Giving Care to Partners During a Breast Cancer Experience, provided relevant information with respect to the current research question. The study was designed to explore some of the experiences that men go through with leisure as well as their implications during the time and after their partners has been taken through breast cancer treatment and diagnosis. During participant recruitment, 46 women expressed interest to take part in the study, with only 49 fitting in the defined criteria; in the aspect of time. Through a detailed snowball sampling, 10 women were enrolled for the study, with each expected to show up with her husband. This saw 10 Caucasian men taking part in the study, aged between 46 and 68 years. Their partners, on the other hand, were aged between 47 and 65 years. 90% of the couple were in a marital status while 10% living common-law. The other important characteristic was the length of the relationship, which varied from 8 and 35 years. Studies by Boquiren et al, titled Sexual functioning in breast cancer survivors experiencing body image disturbance, looked at sexual functioning among the post-surgical breast cancer patients. The study was interested with those participants who had undergone primary breast cancer diagnosis, and went through treatment with curative intent. Under this criteria, the study recruited 127 participants, all who were breast cancer survivors and got engaged in sexual activity. The works of Gopie, ter Kuile, Timman, Mureau, and Tibben (2014) investigated some of the impacts that come with the implant approach as well as the deep inferior epigastric artery Perforator, commonly referred to as the DIEP. The study looked at the resultant impact that the two medical approaches have, not only on body image but the satisfaction that comes with sexual relationship as well. With a well-defined criterion, 131 participants were invited to take part in the study, with only 105 women qualifying for the same. In Understanding normality: a qualitative analysis of breast cancer patients’ concepts of normality after mastectomy and reconstructive surgery, Denford, Harcourt, Rubin and Pusic look at the concepts of normality. This was done among the breast cancer patients who had been proven to be eligible for reconstructive surgery after going through mastectomy. Following the well-laid criterion, the study settled for 35 women, all who had gone through a primary diagnosis of the same. The data collection process was undertaken up to the point when saturation was realized, thus an implication of similar themes emerging at every point.

3.2 Risk Bias

In Women's Educational Needs and Perceptions About Survivorship Following Bilateral Mastectomy, matters to do with recruitment bias and generalizability showed up. The interviews were defined by the participant recall. This implies that the accuracy of the information gathered from the same were based on the probability of recall bias. In Predictors of satisfaction and quality of life following post‐mastectomy breast reconstruction, selection bias took a center stage in the study. This kind of bias arises from the process of participant selection, where two plastic surgeons were mandated to do so from 1 NHS site. Similarly, a larger proportion of the sample was elected to take part in the DIEP reconstruction. In Our organs have a purpose: body image acceptance in Latina breast cancer survivors, the study was subjected to selection bias. The participants were purely from a community-based organization, with the findings failing to generalize to the female cancer patients that are not enjoying any support service. With this kind of biasness, the study cannot be generalized to patient residing in the rural areas and English-proficient Latina women.

3.3 Results of Individual Studies

In Women's Educational Needs and Perceptions About Survivorship Following Bilateral Mastectomy, two themes emerged as the major determinant of education and survivorship. According to the women who took part in the study, their major concerns were inadequacy of information prior to and after the surgery process. They expected to be accorded relevant treatments such as receiving adequate information that will see them making informed decisions. They also opt to be accorded referrals that would see them engage in follow-up services during and after the surgical operation. In Predictors of satisfaction and quality of life following post‐mastectomy breast reconstruction, the outcome of the hierarchical multiple regression analyses shows that up to 75% of the changes in breast satisfaction were attributed to psychological factors. Other than this, the psychological factors led to 68% of outcome satisfaction, and further contributing to 46% for the quality of a post-surgical patient’s life. Similarly, psychological well-being proved to be among the most significant predictors of the level of satisfaction that one has with breast appearance. In Our organs have a purpose: body image acceptance in Latina breast cancer survivors, two themes were identified, with each related the experiences of the cancer patients, with body image. The first theme was the perception of loss as well as reconstruction. The second perception was in line with the process of realizing body image acceptance. The salience of the respective themes was differential, depending on the survivorship stage.

CHAPTER FOUR: DISCUSSION

4.1 Summary of Evidence

The entire studies taken into account in the current systematic reviews have looked at the psycho social impacts of breast cancer surgery on patients, with some extending to their family members. Basing on the findings from the identified qualitative studies, communication, access to treatment and the availability of psychosocial care are the top contributors to the disproportionate burden that women experience during the process of adjusting to the ‘aftermath’ of breast cancer surgical operation. A good example is the case of change in body image, where the post-surgical cancer patients find some difficulty while trying to adjust or be in line with their new body image and shape. Despite this kind of experience, just like in the case of Latinas, limited attention, through literature, has been directed to the same. The findings from the analysed articles are consisted with those of the previous studies. For instance, most of the post-surgical female cancer patients are reported with some lowest rates of reconstruction. This comes alongside limited information with regard to as well as access to the right procedure that they need to adopt. Boquiren et al., (2016) argue that most of the women who go through surgical cancer operations, especially mastectomy and chemotherapy, are reported of body image dissatisfaction. In most instances, their male partners are not impressed with the results, thus reacting negatively as a way of responding to their altered bodies. Considering that this are couples, they end up experiencing disruptions when having sex; just as reported by previous studies. The findings of the systematic review provide a reflection that in deed acceptance has always been one of the gradual processes that is impacted upon by coping strategies, in addition to social support. At the beginning, there are those women who feel horrified by how they look after walking out of the breast cancer operation. However, as time goes by, they start feeling whole again, this begin to appreciate their health more than the look or rather appearance. In the case of those who fail to accept their altered image, they end up feeling ashamed and depressed. Some develop a feeling of unattractiveness; reduce level of femininity as well as sexual desirability. In the case of disrupted sexual activity, some of the participants are left with the feeling that they are rejected. Others develop the poor sense of self-worth, which in turn impacts with the entire process of realizing acceptance.

4.2 Limitations

Just like in the case of other qualitative researches, limitations came into play in the systematically reviewed studies. Among the major limitations were the small sizes of the sample for the respective studies and recruitment bias, in addition to generalizability. Just as Boiler (2016) puts it, limitations of any qualitative research may be in line with or rather have to do with personal skills of whoever is undertaking the research and individual bias. The above concerns hold true and more applicable for the studies underlined for the systematic review. In the entire studies, the selected female participants were in charge of self-reporting information pertaining diagnosis. Most of the interviews were grounded upon the participant recall. In such cases, the availed information is assumed to be quite accurate, taking care of the probability of the recall bias.

4.3 Conclusion

Basing on the findings from the identified qualitative studies, communication, access to treatment and the availability of psychosocial care are the top contributors to the disproportionate burden that women experience during the process of adjusting to the ‘aftermath’ of breast cancer surgical operation. Furthermore, acceptance is one of the gradual process that is impacted upon by coping strategies, in addition to social support. Looking at the case of change in body image, where the post-surgical cancer patients find some difficulty while trying to adjust or be in line with their new body image and shape. Despite this kind of experience, just like in the case of Latinas, limited attention, through literature, has been directed to the same

References

Blumenthal-Barby, J. S., & Krieger, H. (2015). Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy. Medical Decision Making, 35(4), 539-557.

Boiler, J. L. (2016). Women's Educational Needs and Perceptions About Survivorship Following Bilateral Mastectomy. Clinical journal of oncology nursing, 20(4), 411.

Boquiren, V. M., Esplen, M. J., Wong, J., Toner, B., Warner, E., & Malik, N. (2016). Sexual functioning in breast cancer survivors experiencing body image disturbance. Psycho‐Oncology, 25(1), 66-76.

Buki, L. P., Reich, M., & Lehardy, E. N. (2016). “Our organs have a purpose”: body image acceptance in Latina breast cancer survivors. Psycho‐Oncology, 25(11), 1337-1342.

Denford, S., Harcourt, D., Rubin, L., & Pusic, A. (2011). Understanding normality: a qualitative analysis of breast cancer patients concepts of normality after mastectomy and reconstructive surgery. Psycho‐Oncology, 20(5), 553-558.

Gopie, J. P., ter Kuile, M. M., Timman, R., Mureau, M. A., & Tibben, A. (2014). Impact of delayed implant and DIEP flap breast reconstruction on body image and sexual satisfaction: a prospective follow‐up study. Psycho‐oncology, 23(1), 100-107.

Matthews, H., Carroll, N., Renshaw, D., Turner, A., Park, A., Skillman, J., ... & Grunfeld, E. A. (2017). Predictors of satisfaction and quality of life following post‐mastectomy breast reconstruction. Psycho‐oncology, 26(11), 1860-1865.

Shannon, C. S. (2015). ‘I Was Trapped at Home’: Men's Experiences with Leisure While Giving Care to Partners During a Breast Cancer Experience. Leisure Sciences, 37(2), 125-141.