Amy is a fictional name given to the patient in this case study to maintain anonymity.
Amy is a 28-year-old lady referred by her GP to the Triple Assessment Breast Clinic with a palpable right breast lump. Amy had a clinical examination which scored her an E3, the consultant requested a mammogram, ultrasound +/_ biopsy. Amy had all examinations completed and was asked to come back the following week for results. The mammogram reported cystic changes and microcalcifications noted throughout the right breast, left breast of normal appearance. 6 core biopsy samples were obtained. The pathology report concluded grade 2, intra ductal carcinoma plus associated nuclear grade DCIS, ER+, PR+, HER2+. 4 further sites were biopsied. After MDT discussion it was decided that Amy would have neoadjuvant chemotherapy and mastectomy.
Amy: ‘I was prepared to be single for the rest of my life, no hair and a wonky breast how attractive!’.
In addition to coping with the loss of a breast, young women often experience a plethora of negative physical, psychological and psychosocial side effects including substantial scarring, hair loss, weight loss/gain, reduced sexual functioning and satisfaction, depression and poor body image (Kurowecki & Fergus 2014).
Physical attraction is important to the formation of a new romantic relationship. It’s the physical attraction that makes you initiate conversation with someone, it’s what makes you swipe right or left on dating apps (Sharratt et al 2018).
Attractiveness can be dictated by societal appearance ideals, to which visible difference do not conform. There are numerous bald men in society which is acceptable, and many women find it attractive/’turn-on’, however Amy’s baldness is perceived as a sign of a cancer patient on chemotherapy (Brower 2017) as opposed to attractive.
Dating is crucial to the formation of a new romantic relationship but can be challenging and anxiety provoking (Shaw et al 2017). Klitzman & Sweeney (2011) define it as ‘the first step to establishing a lifelong supportive partnership with another individual, with the possibility of starting a family’.
Many young breast cancer survivors like Amy consider dating a key priority (Kurowecki & Fergus 2013), but approximately 50 % of them believe that their image concerns, lack of confidence and fear of rejection impact on their ability to enter a new relationship (Uscher et al 2014) which can lead to further distress and worry (Hoskins et al 2008).
Amy: ‘Oh the questions are multiple, if I did start dating someone nice, how and when to I disclose my cancer history, or do I disclose it?’.
How to reveal this particularly private part of your life to a potential future partner is a major concern (Ruddy et al 2013). Exactly how much detail women want to provide must be decided as well as how and when this information should be communicated (Klitzman & Sweeney 2011). Mutual disclosure plays a vital role in the development of any new intimate relationship (Sprecher et al 2013), lending to greater closeness.
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Kurowecki & Fergus (2014) research revealed that many young women perceive the dating process as a series of tests, whereby they reveal little by little in order to ascertain the potential future partner’s ability to cope with the disclosures. The relationship can continue to physical level should the potential partner ‘pass’. Women are ‘highly attuned to the potential to be hurt’ (Kurowecki & Fergus 2013) and the possibility of being sexually intimate created feeling of anxiety and worry.
Amy: ‘The thought of being intimate with anyone again, scares me to death’.
Physical changes due to treatment can leave many young women feeling deeply unattractive, leading to low sexual self-esteem and undesirable to a potential future partner. It can cause apprehension about entering a physical relationship. Treatment side effects can also challenge women’s psychosocial and psychological well-being, which can have an impact on sexual satisfaction and functioning (Holmberg et al 2001), which include loss of libido, menopausal symptoms and discomfort/pain during intercourse (Kurowecki & Fergus 2013). Many young women will tend to avoid situations that may lead to sex, as they may feel discomfiture at being seen naked.
In a study by Sharratt et al (2018) one participant revealed how her visible changes had the ability to ‘steal the moment’, just by moving her head on the pillow reminded her of the fact that she has no hair.
Issues such as contraception need to be discussed with the patient, reliable and reversible non hormonal methods as well as permanent methods need to be considered (Cardoso et al 2012).
Amy: ‘My late 20’s I feel this is the time of my life I should be out partying and socialising, letting my hair down not watch it falling out’.
Numerous young women with breast cancer, diagnosed in their 20s and 30s feel robbed of time. This is a typical time to be out socialising and potentially meeting a lifelong partner and starting and new family. A breast cancer diagnosis in this chapter of life can delay reaching all these milestones (Corney et al 2014).
Amy: ‘If I did meet the man of my dreams and he wanted children would I be able to give them to him?’.
For young women with BC, future fertility is a major concern. Many premenopausal women can experience temporary or permanent chemotherapy induce amenorrhea (CIA) (Howard-Anderson 2012), which impairs ovarian function which is especially important in those who desire future pregnancy. Up to 70% of women under the age of 40 years can experience CIA (McCray et al 2016)
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For Estrogen Receptor (ER) positive BC, adjuvant hormone therapy is typically recommended for a period of 5-10 years post diagnosis (Davies et al 2013) because of the teratogenic effect of BC treatment, pregnancy is contraindicated, which further delays childbearing plans in women who already have a diminished ovarian reserve (Torino et al 2014).
Young women diagnosed with breast cancer have very specific future concerns, from coping with the physical changes and emotional anxieties to dating and the possibility of having children. Young women who experienced changes in their physical appearance due to breast cancer treatment fear judgement and anticipate rejection. Ben Charif et al (2015) stated that women who were well informed and given the relevant information on the various issues pertaining to them as individuals experienced an enhanced quality of life and minimised the negative impact on intimate relationships. McCray et al (2016) also concluded that improvements in the dissemination of information, to include all available treatment options, will help young BC survivors make decisions for the future.
‘Breast cancer is ‘just something that happened to them…... it doesn’t define them’. (Freidus 2017).
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