Introduction and background:
The word “cancer” itself is traumatic in nature. It effects a person not only physically but also psychologically, financially, culturally, socially, and spiritually etc. According to World Health Organization( WHO) report (2014), in 2012 worldwide 14.1 million adults were diagnosed with cancer, and among them 8.2 million were died. Moreover, breast cancer is the fifth leading cause of death. In the USA, among all types of cancers the breast cancer is the highest incidence rate because one in ten women is having breast cancer (Njeh, Saunders, & Langton, 2012). Breast cancer incidence increased more than 20% (WHO Press Release, 2013). Furthermore, cancer is also one of the leading causes of deaths in the developing countries. In Pakistan, the most frequently diagnosed cancer is breast cancer for females. The incidence of breast cancer is higher in western countries but Pakistan has the highest rate of breast cancer among all the Asian countries, (Pink Ribbon Pakistan). It is estimated that 1 in 9 Pakistani women will develop breast cancer at some stage of their life. (Shokat Khanum Cancer Hospital and Research Center). The cancer patient suffers a lot from the physical and psychosocial problems not only because of the disease process but also from the treatment related problems. As, one out of two patients with cancer experience psychiatric disorder especially depression (Reyes-Gibby, Anderson, Morrow, Shete & Hassan, 2012; Spoletini, et al, 2008).
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There are certain treatment modalities for cancer such as surgery, chemotherapy and radiotherapy. Each of them is potential to produce various threats for the cancer patient. Radiation therapy is also an important treatment performed before and after surgery which also has various harmful effects on the patient. Beside that it is significant part of cancer treatment but its impact on patient’s quality of life and nursing management is less addressed in literature. According to Welle, (1998) radiotherapy patients are perceived as self-caring and their needs are not taken care of.
However, numerous researches have been conducted nationally and internationally to identify the different problems and their intervention of the cancer patients treated with chemotherapy and surgery. As a result evidence based body of knowledge have been generated this is contributing in quality nursing care and health teaching, impacting on the patient’s quality of life. Moreover, some of the international studies highlighted the problems faced by the patients receiving radiation therapy but as per my best knowledge very little work has been done in the field of nursing to remedy these problems. Most importantly, in the context of Pakistan very little work has been done pertinent to this issue.
However this study is significant to contribute in the existing body of knowledge for nurses to care for breast cancer patient more holistically. Moreover, this study may be helpful to develop the teaching material for patients receiving radiotherapy to enhance their quality of life. In addition, the findings of this study will be helpful for nurses working in Pakistan.
This study may improve the teaching interventions of nurses caring for cancer patients in government hospital and may have positive effect on their knowledge, attitude, and skill pertinent to RT.
The aim of this paper is to identify the physical and psychosocial problem of the patient pertinent to radiation therapy, as well as the nursing management and health teaching for the patients for enhancement of their quality of life.
Question 1: What are the different physical and psychological problems of the breast cancer patients undergoing RT in Pakistani context?
Question 2: Is there any association between RT and compromised quality of life of the patient.
Question 3: What kind of health teaching is necessary for the nurse to give the patient before and after RT?
Question 4: what are the feeling and perceptions of breast cancer patients undergoing radiation therapy ?
The review of literature was conducted through data bases CINAHL PubMed , Mosby’s Nursing Consult, Science Direct, and Google Scholar were search for published research articles relevant to this paper. The combination of the following key terms was used to retrieve relevant literature by punching “physical/psychological problems, breast cancer, problems with radiation therapy, quality of life, patient education etc”. Search generated 283 articles, 52 duplicate results excluded. Through a selection process title and abstract screened, among those 20 were found to be relevant to the topic.
Radiation therapy is one of the options totreat the cancer, uses high-energy x-rays or gamma rays targeted at the tumorto shrink the tumors or kill cancer cells(Radvansky, Pace, &Siddiqui, 2013). During the course of the treatment about two-thirdsof patients will undergo radiation therapy(Guo et al. 2013).According toPotthoff et al (20013). More than 90% of all breast cancer patients receive adjuvant radiotherapy, given after breast conserving surgery as well as after mastectomy to avoid recurrence of cancer. Darby et al (2011) found in their meta-analysis study that RT after breast conserving surgery reduces 15-year risk of breast cancer death rate from 25•2%. This widely used therapy has its side effects like other cancer treatments; it is also potential for causing great physical as well as psychosocial problems as other cancer treatment do (Egestad, 2013).
Physical problems related to radiation therapy for breast cancer patients
Radiation therapy affects cancer and normal cells equally within the treated area, result in injuryof the cells which lead to side effects. The radiation therapy induced side effects include skin and mucous membrane toxicities, sleeplessness, pain, swelling, dyspnoea, cough and nausea. (Rose, 2011; Darby et al, 2011; Adams, 2009;Currie& Wheat 2006; Gordils-Perez,&Duell,2003).Skin problems are the most frequent side effect among all and nearly 85%–95% of patients receiving radiation therapy will develop some degree of skin damage (Bergstrom, 2011). There are many long term side effects of breast irradiation like cosmetic changes hyper pigmentation, fibrosis, lymphedema, and damage to underlying normal structures (Perez,&Duell,2003). Therefore it is very important to remedy this problem because this side effect of radiation therapy limits the patient’s ability to tolerate the treatment (Currie,Wheat, 2006).In their study Potthoff et al (20013) .reported that 80% of the patients experience fatiguewho receive RT. They defined fatigue is a “persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning and that is usually not relieved with rest and is not related to an excessive amount of activity” (p.3).In another qualitative study Poirier, (2011) found out that fatigue is also very common in patient getting radiation therapy and it affects their role functioning in daily life. In this way the fatigue may affect the quality of life of the patient. Another side effect of RT is reported in of the studies is sleep disturbance. According to the study conducted by Dhruva, et al (2012).approximately 50% breast cancer patients reported sleep disturbance at the initiation of radiation therapy.
Quality of life of the patients
Breast cancer due to its poor prognosis and treatment related problems affect the quality of life of the patient. Kirchheiner et al. (2013) reported that “mean QOL in the total cohort is 58±27% (100% indicates excellent QOL)” (p.425). Similar to other treatment choice RT related side effects also have impact on the quality of life of the patient. The quality of life is defined by WHO (1997) “concept affected in complex way by the person’s health, psychological state, and level of independence” (p.1). As the National Cancer Institute (2011). Mentioned that 38% of all women diagnosed with breast cancer experience abandoned symptoms resulting from the disease and its treatment. Therefore, the side effects of RT affect the quality of life of the patient (Currie, & Wheat, 2006). In addition, sleep disturbance is another problem found to be an important contributor in affecting the quality of life of the patient. In this connection, a study conducted by Graydon (1994) highlighted that sleep disturbance and fatigues were the main areas of the life of women affected by RT. Since the fatigue, influence the physical, cognitive and emotional aspects and the prevalence ranges from 30-70% in women with breast cancer, reaching up to 80% when they are undergoing radiotherapy (Alcantara-Silva, Freitas-Junior, Freitas, & Machado, 2013). This is one of the most frequent side effects of radiotherapy, and it may interfere with self-esteem, social activities and quality of life.
Moreover, the fatigue and pain related to radiation therapy may affect the sexuality of the patient by decreasing the desire and arousal and skin changes including burns and tattoos affecting body image and self-esteem (Varela, Zhou, & Bober, 2013; Mercadante & Vitrano & Catania , 2010). These symptoms lead to compromised quality of life of the patient. In this regard nurses need to give the high quality care by addressing the all aspect of patient life to enhance the QOL of their patients undergoing RT. Moreover, with the advancement of health science the patients expectquality oflife (QOL) beyond just survival
The women diagnosed with breast cancer have remarkable impact on her psychological well being. As Halkett , Kristjanson , and Lobb (2008) highlighted that women with breast cancer receiving radiotherapy, experience many kinds of fears like fear of unknown and getting burnt, damage to internal body parts, and anticipating tiredness. These kinds of fears may threaten the women which may have negative impact on compliance with the treatment. Rose, (2011) highlighted that patient may feel high level of stress at the start RT because of unfamiliar technology, potential side effects and being in an environment with other cancer patients.
Moreover, the outcome of the study of Reyes-Gibby et al. (2012) shown that depression among women was positively associated with symptoms of disease and treatment. Thus the diagnosis and treatment can have a profound influence on a woman’s psychosocial and overall well-being.
Role of nurse in RT patient’s care and education
The above mentioned literature suggests that patients who receive radiation therapy face significant challenges and require care during the period of their treatment. Nurses are direct care provider in any health care setting. They play a significant role in their specialized field in various health care settings. Therefore, they can play a significant role in improving quality of life of the cancer treatment recipients. During the RT course, patients may go through many complex physical and/or emotional responses (Rose, 2011). A randomized trial study conducted by Christman, & Cain, (2004) concluded that patients receiving concrete objective information reported maintaining higher levels of usual function than those not receiving. Furthermore, giving information about symptom experiences helped them to mentally prepare uncertainty about their symptom experiences. Oncology nurses need to own the responsibility of their patient and identify the patient need. The Meta analytical findings support the usefulness of
psychosocial interventions for improving QoL in adult cancer patients.
In this regard a comprehensive nursing care of the patient can improve the physical as well as psychological care of the patients.
Importance of Patient education
Providing cancer patients with appropriate information regarding their treatments, side effects of treatment and coping strategies allows them to feel more control over disease and its related problems. It helps them make better choices of treatment modalities ( Barnett, et al. 2004). The study findings of Zeguers et al (1012) highlighted that now the RT patients want comprehensive information about their disease, treatment, and procedures, side effects, and prognosis with the mean scores between 4.1 and 4.4 on a scale from 1 to 5. In contrast ,Barnett, et al. (2004). Emphasized that information needs vary among different individual therefore, a patient-centred approach must involve according to the tolerance and need of the patient.
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