Introduction and background
Breast cancer is the most common cancer among women and leading cause of cancer related deaths of this gender (World Health Organization, 2014). Previously it was most common in developed countries but now it became commonest cancer both in developed and developing regions (Ferlay et al., 2010). Moreover, in USA, breast cancer has the highest incidence rate among all types of cancers involving one in every ten women (Njeh, Saunders, & Langton, 2012). However, in Pakistan the incidence is more alarming as 1 in every 9 women is at the risk of developing breast cancer (Siddiqui, n. d.). This data indicates that Pakistan has highest incidence rates of breast cancer in Asian countries (Aziz, Sana, Akram, & Saeed, 2004; Bhurgri, et al., 2000; Naeem, 2008). Furthermore, Hussain, Ahmad, Muhammad, Kakakhail and Matiullah (2008) identified the incidence of breast cancer 96. 49 % among women registered in Institute of Radiotherapy and Nuclear Medicine, Peshawar, which are more frightening figures.
There are certain treatment modalities for breast cancer among them radiation therapy (RT) is an important treatment choice, performed before and after the surgery which also have various side effects. During the course of treatment, about two-thirds of patients undergo radiation therapy, before and after surgery (Guo et al., 2013). In addition, more than 90% of the all breast cancer patients receive adjuvant radiotherapy to prevent the recurrence of the disease (Potthoff et al., 2013). Despite its wide use and significant role in cancer treatment, few studies addressed the experiences of its recipients. According to Welle (1998) radiotherapy patients are perceived as self-caring and their needs are not taken care of. The international literature indicates that breast cancer patient receiving RT not only suffers from disease process but also from the side effect of this treatment. The nature of disease, its prognosis and treatment related problems have devastating effects on physical, psychological and socio-economic wellbeing of the patient (Farooqi & Chaudhry, 2012; Kirchheiner et al, 2013). However, these studies have been conducted in western context on different population which has stark difference in our culture. In addition, within the Pakistani context, Khyber Pakhtunkhawa is considered more conservative province. Therefore, it is important to explore experiences and problems of the local population to remedy their problems. Furthermore, data from Pakistan revealed that breast cancer was found mostly in younger age group ranging from 30-50 years as compare to west where it tend to occur in women above 60 years of age (Aziz, Sana, Akram, & Saeed, 2004; Mamoon, Sharif, Mushtaq, Khadim, & Jamal, 2009; Naeem, et al., 2008; Tfayli, Temraz, Abou Mrad, & Shamseddine, 2010). Importantly, this age group is more productive and may have different responsibilities pertinent to their age group towards their family and society which may vary from western population in term of their concerns, needs and issues. However, in Pakistan, research in this area is not conducted to explore the experiences of breast cancer patient receiving radiotherapy therefore; research is a required to address the issues of this population. In addition, this is the first study of its nature in Pakistani context especially in Khyber Pakhtunkhwa in the field of nursing which will increase the awareness regarding radiotherapy related problems of patients among nurses and other health care providers.
This study is significant to generate information for nurses to care for patient undergoing RT in Pakistani context. It will help nurses to understand the feelings and experiences of the patients undergoing RT to design nursing care plan by addressing their needs. Moreover, findings of this study can help to identify recommendation for health care staff working in the radiotherapy units to facilitate their patients undergoing radiotherapy in a better way. It will also help health care professionals maintain a sense of the importance of the experience of the RT patient who are coming to them for treatment and want their care pertinent to their needs.
The aim of this study is to explore the experiences of the female breast cancer patients undergoing radiotherapy.
What are the experiences of the of breast cancer patients undergoing radiation therapy in Khyber Pakhtunkhwa, Pakistan?
The review of literature was conducted through data bases CINAHL PubMed, Mosby’s Nursing Consult, Science Direct, and Google Scholar. Search for published research articles relevant to this paper was done. The combination of the following key terms was used to retrieve relevant literature “ physical/psychological problems, breast cancer, problems with radiation therapy, quality of life, experiences of breast cancer patients. Search generated 283articles, 52 duplicate results excluded. Through a selection process title and abstract screened, among those 30 were found to be relevant to the topic.
Radiotherapy is one of the essential components of the cancer treatment. It minimizes risk of recurrence, improve survival rate (Bese, et al., 2006). This is done by using high-energy x-rays or gamma rays targeted at the tumor to shrink the tumors or kill cancer cells (Radvansky, Pace, & Siddiqui, 2013). During the course of treatment, about two-thirds of patients will undergo radiation therapy, before and after surgery (Guo et al., 2013). Beside this adjuvant radiotherapy is advised after breast conserving surgery as well as after mastectomy to minimize the chances of reoccurrence of the disease. As Darby et al. (2011) found in their meta-analysis study that RT reduced 15-years of risk of breast cancer related death rate after breast conserving surgery. Beside its effectiveness, it exerts multiple physical, psychological and socio-economical problems on patients.
Physical problems related to RT
Radiation therapy affects cancer as well as normal body cells within the treated area, result in injury of the cells which lead to many side effects. The RT induced side effects include skin and mucous membrane toxicities, sleeplessness, pain, swelling, dyspnea, cough and nausea. (Adams, 2009; Currie & Wheat 2006; Darby et al, 201; Gordils-Perez, & Duell, 2003; Rose, 2011). In addition, skin problems are the most frequent side effect of RT which affects nearly 85% to 95% of patients and also cause skin damage (Bergstrom, 2011). Additionally, there are many long term side effects of breast irradiation like cosmetic changes hyperpigmentation, fibrosis, lymphedema, and damage to underlying normal structures (Gordils-Perez, & Duell, 2003). Moreover, fatigue, soreness and dryness of throat, headache, and desquamation were also common symptom reported by patients receiving RT (Sherminie & Cottrel, 2014). Among them fatigue is reported by 80% of the patients receiving RT which affects the role functioning of breast cancer female in their daily life (Poirier, 2011; Potthoff et al., 2013). The RT patent also endure sleep disturbance as Dhruva et al. (2012) reported that approximately 50% breast cancer patients have sleep disturbance at the initiation of radiation therapy. 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. It influence the physical, cognitive and emotional aspects of the 80% of breast cancer patients underwent RT (Alcantara-Silva, Freitas-Junior, Freitas, & Machado, 2013; Stone, Richards, Hern & Hardy, 2001). As Currie and Wheat (2006) suggested that it is very important to address and remedy the evident side effect of RT because these are capable of limiting the patient’s ability to tolerate the planned treatment.
Breast cancer remarkably affects women’s psychological well-being. One out of two patients with cancer experience psychological disorder (Reyes-Gibby, Anderson, Morrow, Shete& Hassan, 2012; Spoletini, et al., 2008). Beside the disease process its treatment modalities also contribute in the psychological problems of the patient. As, Reyes-Gibby et al. (2012) proved that depression among women have positive associated with symptoms of disease and treatment of the breast cancer. In addition, RT is usually prescribed before and after surgery which tend to have its psychological effects on patient. A qualitative study conducted in Sri Lanka to explore the experiences of breast cancer patients undergoing radiation therapy, concluded that women feel fear of treatment, machines used in treatment and blackening of the skin. The study also reported patients feel uncomfortable and stressed in the presence of male staff members and waiting for long time in RT department (Sherminie & Cottrel, 2014). In addition, Halkett, Kristjanson, and Lobb (2008) highlighted in their qualitative study, that the patients with breast cancer receiving radiotherapy, experience many kinds of fears like getting burnt, damage to internal body parts, and anticipating tiredness. These kinds of fears may have negative impact on compliance with the treatment regimen. Rose (2011) highlighted that patient feel high level of stress at the start RT because of unfamiliar technology, fear of potential side effects and being in an environment with other cancer patients. A literature review carried out by Lim, Devi, and Ang (2011) concluded that anxiety is predominant psychological issue of the all treatment modalities of the breast cancer across the globe and continue beyond the acute stage of treatment. In relevance to RT it is experienced by10 to 20% of the patients (Stielgelis et al., 2004). Moreover, the fatigue and pain related to RT may affect the sexuality of the patient by decreasing the desire and arousal and skin changes result in burns affecting body image and self-esteem (Mercadante, Vitrano & Catania, 2010). Therefore, the diagnosis and treatment can have a profound influence on a woman’s overall psychological well-being thus compromising the quality of life of the patient.
Breast cancer patients face multiple socio-economical problems because the cancer treatment is very expensive which may not be affordable for many of the patients particularly who belong to low income families. A well-established literature signifies that breast cancer patient treated with surgery also receives RT which may be additional financial burden for them especially in the limited resourced countries like Pakistan. Most of the developed countries of the world, large part of expenditure of the cancer treatment are paid by the government, but in Pakistan, the costs of the therapy are borne by the patient and their families (Zaidi, Ansari, & Khan, 2012). Many breast cancer patients in Pakistan experience finical difficulties and use their savings to pay for treatment (Banning, Hassan, Faisal, & Hafeez, 2010). Moreover, statistics also highlights that the incidence of breast cancer is increasing in countries with inadequate resources thus limiting the access to radiotherapy (Bese, 2006). Due to finical barriers, Pakistani female breast cancer patients face different challenges throughout the course of the disease (Ahmed, Shaikh, & Hasan, 1997). Apart from economical issue woman with breast cancer faces many social and cultural problems in Pakistan. A qualitative study by Banning, Hassan, Faisal, and Hafeez (2010) reported that in Pakistani culture breast is considered a hidden organ that should not be exposed, discussed or touched by others. They also highlighted that most of their participants reported stigma attached to a diagnosis and likelihood surgery therefore they hide their diagnosis from family and local community. Furthermore, in conservative culture of developing countries female are less empowered and given low priority and their health issues are least bothered by the society (Tfayli, Temraz, AbouMrad, & Shamseddine, 2010). In this regard, female with breast cancer may experience unbearable problems which may not be experienced by women of different cultural and social class (Aziz, Sana, Akram, & Saeed, 2004).
Knowledge of Treatment
The above mentioned literature suggests that patients receiving RT face significant challenges and require appropriate information regarding their treatments, side effects of treatment and coping strategies allows them to feel more control over disease and its related problems. Such as, Halkett et al. (2012) emphasized that undergoing RT is difficult experience for patients which needs appropriate and specific information to have the better outcomes of the therapy. Though, the RT is an important treatment but their patients are found to be poorly informed (Halkett, Kristjanson, & Lobb, 2008; Sherminie & Cottrell, 2014). This may contribute in their fear, anxiety, stress, and compliance with treatment. Thus the appropriate information and guidance help the patient to make better choices of treatment modalities (Barnett et al., 2004). In addition, findings of a quantitative study by Zeguers et al. (2012) showed that 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-centered approach must involve according to the tolerance and need of the patient. A randomized trial study conducted by Christman and Cain (2004) also 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 tackle uncertainty about their symptom experiences.
The incidence of the breast cancer continues to rise worldwide. Multiple treatment modalities have positive impacts on prognosis of the cancer. Radiotherapy is one of the commonly used treatment modalities having its side effect as well. Moreover, available literature suggest that a series of problems faced by patients receiving RT. But, there is a profound need to develop clear understanding of the phenomenon that what patients experience when they undergo RT. Moreover, nursing literature needs to address the needs of these patients and recommend evidence based interventions to help them. Furthermore, in the context of Pakistani conservative culture women with breast cancer may be experiencing different problems than western women. Therefore, this study question needs a qualitative study to arrive at the desired outcome of better understanding of the situation.