NIP3331 Nursing Practice: Impact of Mastectomy | Breast Cancer

Topic

The impact of mastectomy on unmarried Nulliparous woman age 25-45 years in the UK with breast cancer.

Aim: to explore the effects mastectomy of unmarried Nulliparous woman age 25-45 years in the UK with breast cancer.

Research Question: what is the impact of mastectomy on unmarried Nulliparous woman age 25-45 years in the UK with breast cancer.

Objectives

To systematically review the impact of selected primary research articles regarding the impact of mastectomy on unmarried nulliparous women age 25-45 in the UK with breast cancer.

To review and reflect on theories and nursing management of mastectomy on nulliparous women with breast cancer pre and post surgery

To analyse and reflect on the government health policies initiatives in the management of mastectomy on women with breast cancer and to discuss the results, conclusion and recommendation for future, research in regards to mastectomy.

The issue relevant to the nursing management of nulliparous women with breast cancer pre and post surgery is essential to the understanding of the effects of mastectomy in the concerned population. The studies related to this matter although scanty, yet there are evidence and empirical findings that have rendered vital insight into the exploratory topic for the sake of better understanding and deeper probe in this regard. The study findings have crucial implications for defining definite strategies and interventions to tackle the issue in the vulnerable individuals thereby aiding in mitigating the condition and preventing deteriorating effects of the disease. In UK there lies a scarcity of studies that have addressed the topic of the impact of mastectomy on an unmarried Nulliparous woman. The present literature review would be serving as a synopsis of literature existing on the chosen research topic. The results derived from the review would become a ground of strategies that can be considered for implementation in future by healthcare sector in the quest of delivering optimal care to patients undergoing a mastectomy. The existing policy framework of patient care post-mastectomy can be changed on the basis of the finding of the review, and this would lay the provision for positive changes in healthcare practice.

Research question 

What is the impact of mastectomy on unmarried Nulliparous woman age 25-45 years in the UK with breast cancer?

Research aim

To explore the effects mastectomy of an unmarried Nulliparous woman age 25-45 years in the UK with breast cancer.

Research objective

To systematically review the impact of selected primary research articles regarding the impact of mastectomy on unmarried nulliparous women age 25-45 in the UK with breast cancer

To review and reflect on theories and nursing management of mastectomy on nulliparous women with breast cancer pre and post surgery

To analyse and reflect on the government health policies initiatives in the management of mastectomy on women with breast cancer and to discuss the results, conclusion and recommendation for future, research in regards to mastectomy

Search strategy

Database used- The systematic review was carried out by searching for appropriate literature in the electronic databases that are the pool of authentic information on diversified subjects. The electronic databases used for the review were EMBASE, Science Direct, MedlinPlus, Cochrane, WebMD and PubMed. These databases provided a wide range of articles upon which proved suitable for the review. Full-text articles were available in these databases, and therefore it was easier to assess the credibility and validity of the articles for inclusion in the review (Matthews and Ross 2014).

Keywords and Boolean operation- The articles were searched using the keywords relevant to the research question. These were the important phrases and words extracted from the research objectives used for successfully retrieving data. The key words used were- breast cancer, nulliparous, unmarried, women, surgery, mastectomy, United Kingdom, UK, impact, effect, age young, management, treatment, body, health, policy. The keywords were used in conjunction with Boolean operations that helped in carrying out a focused search. The results were productive since there was a desirable elimination of the irrelevant hits. Use of Boolean operations make the search process faster and convenient (Panneerselvam 2014).  The Boolean operations used were AND. OR.

Inclusion criteria- The articles selected had been published after the year 2011. The articles matching the research question were considered for the review.

Exclusion criteria- The articles with a published date before the year 2011 were not considered for the review. The articles that did not relate much to the topic were discarded.

Final selection of articles-The articles was considered for rigorous screening for understanding whether they were relevant to the research topic or not. The abstract of the articles was first scrutinised for this purpose. The full articles were then read in the second round of screening for the final selection of the articles. The results of the review have been presented in the next section.

Literature review 

Lewis-Smith (2015) sought to understand the impact of breast cancer on the body image of women. The researcher conducted a literature review encompassing some valuable research articles and papers on the concerned topic. Breast cancer is the most common cancer prevailing among the women in the United Kingdom. Advancements in medicine have contributed to the improvement in survival rate while the number of women facing residual consequences of breast cancer is growing. Women can undergo a wide range of treatment options, most likely in successive order, that brings about different changes in the appearance of the individuals. The alterations in the appearances have an adverse impact on the body image. Women, as a result, face substantial distress.

The researcher has put up a discussion on how appearance in women is affected as a result of breast cancer treatment. As a result of the partial or at times complete loss of both or one of the breasts, surgery often leads to asymmetry in breasts, severe scarring, the need of using a breast prosthesis, loss of breast sensation, lymphedema and breast reconstruction. Mastectomy is the most commonly applied procedure, as indicated by the National Mastectomy and Breast Reconstruction Audit and around 16485 women have been reported to have received the intervention since the year 2008 in the UK. 21% of the women falling under this category had opted for immediate reconstruction. Around 10% of the population had undergone a delayed reconstruction after a mastectomy. Chemotherapy leads to wide array of side-effects responsible for changing appearance. Such changes include weight fluctuations, hair loss, hot flushes at the time of menopause, nail discoloration and skin discoloration. Challenges are faced by women when the radiation treatment has a negative impact on skin, giving rise to skin reactions. Moreover, long-term changes in the neurological system  also occurs that is slow progressive in nature. Hormone treatments might bring an early onset of menopause and the related body changes. A large section of British women receives a combination of these treatments and thus have to deal with multiple negative impacts at a time. These extensive range of significant alterations may have their impact over a long time period.

Lewis-Smith (2015) has deeply-analysed the impact of changes in body images in women after mastectomy. As per the author the wide ranging alterations in the appearance form to be a major sourse of body dissatisfaction and distress for those women who undergo mastectomy. This is more so because they are not in control of the inidivduals. One study cited by the researcher had reported that appearance concerns arose in around 33% women undergoing mastectomy within 7 months of the surgery. In addition, these arising disturbances can remain for a long time post surgery. Predominantly incapacitating upon self body image are any hair loss. changes seen in breasts. Women perceive their breasts to be associated with feminity, sexuality, attactivenees, nurturance. A loss of breast is therefore a devastating situation for women whereupon the feelings of loss of sexuality and feminity are lost. After a surgery has been done women report that they have a feeling that a part of their body is missing oras if they have been mutilated. Scarring from mastectomy have a deep negative relationship with feelings of sexuality and body image. Body dissatisfaction among the women is of high intensity, the impact of which is in the  social life they lead. Women undergoing mastectomy have a tendency to avoid socialising and isolate themselves from the society. Studies have reported that only half of the women who have undergone the procedure of mastectomy would like to choose undergoing the same procedure again in life if needed. This decision is based strongly on the awareness of the individuals about psychological challenges. For a women, her hair holds value of reflecting gender, beauty, religious affiliations and age across many cultures, while having an imperial relationship life and body growth. Loss of hari due to mastectomy is often a traumatic experience for the individuals as it imposes a long-lasting detrimental impact on self-concpet, sexuality and body image.  For these women, hair loss is probably the most distressing and disturbing side effect of mastectomy, more specifically radiation therapy. Hair loss, as compared to loss of breast is more devastating as hair is embedded in the women’s sense of identity.

The researchers scrutinised how body image of women can be improved considerably. Psychological interventions that make the body image of women the target have bee considered for analysis in the past. Nevertheless, current research strongly supports the effectiveness of interventions based on cognitive behaviour therapy to be applied to such patients. This support comes up in the light of the research indicating that this therapy has multiple benefits. The approach of the therapy considers the application of techniques such as cognitive restructuring, goal setting. The target of the therapy is dysfunctional thoughts, behaviours and emotions. Different physical-activity based programs have been proven to be improving appearance dissatisfaction. One such form is yoga that has immense potential of bringing positive outcomes. Though many research studies had previously highlighted the impact of body image in women with mastectomy in a certain degree, further studies are warrened in this area. More rigour of the methodology is required in terms of evaluation and research design. It is to be mentioned in this regard that randomised controlled trial with well adjusted sample size and proper periods of follow up would be better.

Lambert and Rusby (2014) explored the experiences patients have after undergoing mastectomy without reconstruction. The  authors pointed out the last few years have witnessed a tendency to put up short stays at health care settings after mastectomy. The Cancer Reform Stratgey laid out in 2007 had suggested that the maximum time for which a patient needs to be staying at the hospital is 23 hours. Introduction to changes in the ambulatory breast care model had been thereafter taking place in England. However, a number of healthcare professionals had been initially sceptical about the discharge of women soon after the surgery is performed. Nine eligible women took part in the study among whom some were child bearing whereas others with nulliparous. Four themes emeged from the study; preparation and initial response, the experience at the hospital, coping strategy’s effectiveness after discharge and the desire to get back to the normal life. the participants reported that they were glad to be back home just after 23 hours of the surgery. They expressed concerns regarding how the family members would be able to come to terms with the major change and how the patient would be successful in managing the change brought about. Though there was apprehension at the intial phase, the patients soon embraced the provision to be discharged home. Some participants reported that they preferred staying at the hospital for longer duration just to ensure that they were safe and free from any sort of physical risks. Patients also showed concern regarding management of other health complications like diabetes. Coping mechanisms after getting discharge from the hospital was adequately highlighted in the study. After getting discharge patients felt that they were better able to take control of the recovery process. They were better able to pace themselves and take adequate rest as necessary. The general impression was of being happy and content. This was achieved more due to support from friends and family members. The near and dear ones played a crucial role in enabling the patients to better manage their conditions. Participant living alone reported that she was able to implement necessary measures for managing her condition with the help of her friends.

The article also brought into focus the importance of support from the clinical nurse specialists in due course of managing mastectomy. The participants stated that the nurse specialists were empathetic and concerned regarding the ability of the  patients to deal with the surgery. During times when the patients felt lost and had feelings of hopelessness, it was the  nurses who provided support and encouragement to deal with the situation and come out with positive physical and mental well-being outcomes. The needs of the patients were anticipated adequately by the nurses and this proved to be the building block of an effective informal relationship between the patients and the nurses. Coping emotionally ith the overall surgical process was made easier with the presence of the nurse. Adequate patient  information delivered in a culturally sensitive manner deserves special mention in here. One common aspect found in the accounts of all participants was the desire to get back to normal life. The policy outlined that focused on early discharge established itself to be a driving factor behind mindsets of patients. They were longer considering mastectomy to be a major surgery and were open to the impacts that would occur successively. A well organised and managed discharge was expected by the patients. The clinicians herein played a role in educating the patients and empowering them to gain back control over their lives and organise themselves back into their lives.  

The above-discussed study had the focus on a small cohort of women, and therefore the observations  need to be justified in the lights on more broader studies. Phenomenology is the research approach for documentation of the experiences and perceptions of individuals. The present study provided a number of priceless insights into the manner in which patient is undergoing mastectomy overcome the challenges faced in life after the surgery. The study confirmed that patients after mastectomy rely on the nurses, families and friends for overcoming the problems and difficulties faced in different spheres of life. Such kind of qualitative research is more needed in the country.

Holland, Archer and Montague (2016) conducted a study to understand the younger women’s experiences of deciding against the delayed breast reconstruction after mastectomy following breast cancer. The research was a phenomenological analysis and therefore a valuable one. As per the authors, the section of the women population who do not consider breast reconstruction after mastectomy is huge in number. The experiences that young women have, after being determined of adhering to the decision, was largely absent in existing literature of that time. Under this circumstances the researchers decided to undertake an interview-based investigation based upon interpretative phenomenological analysis for exploring the experience of six women who were diagnosed with primary breast cancer. The age of the women was between 30 and 40 years. They participants reported making delayed decisions regarding reconstruction. The findings of the study reported that one profound emerged from the interview and this was decision making. The larger analysis illustrated that the drive and intention of women to survive after mastectomy has a clear influence on their decision making process at the initial phases. The tenacity demonstrated by the women for maintaining the decision is high, though non-reconstruction might be perceived as a negative aspect at certain instances on medical grounds. The women duly acknowledged that there is a need for positive messages pertaining to re-construction of breasts. The medical teams play a crucial role in this regard who are to provide with formal resources. Moreover, media coverage, images and informal literature are not successful in being a positive representation of non-reconstructed women bodies. Non-reconstruction is therefore not in a position to be qualified as a balanced way in the viewpoint of the younger women. Under certain circumstances, there had been negative relationships between the women and the medical teams. However, there was a limitation of the study. As the women who were the research participants  were diagnosed with breast cancer at least five years before the research was conducted, information received from the research was not comprehensive.

Rubin and Tanenbaum (2011) analysed the present situation within the society pertaining to breast cancer, mastectomy and decisions regarding breast reconstruction among sexual minority women. The authors had cited that one prospective study undertaken in the United Kingdom with 103 participants indicated that there was no difference between the extent of satisfaction among women after reconstruction of breasts following mastectomy. This study also found no differences in psychological distress with the participant's cohort. Rubin and Tanenbaum undertook a primary data analysis with thirteen bisexual or/and lesbian undergoing a mastectomy. The individual qualitative interview was conducted for exploring the decisions regarding reconstruction. The concluding concept from the study was that breast reconstruction could be considered as a strategy for symbolically defending against anxieties that patients go through after mastectomy. It is to be noted in this context that the culture of breast cancer in the modern times is constantly evolving the illness into a feminity symbol. The methodology of the present study precludes from drawing a conclusion regarding the impact of mastectomy on bisexual or lesbian. Nevertheless, the study suggested that women belonging to the sexual minority group have the same anxieties and emotional issues regarding loss of breast as those experienced by heterosexual women. This is due to the fact that this group of women are linked with the representation of existential anxieties that are often masked by concerns of the culture.

Neuburger et al. (2013) brought forward the trends in the use of bilateral mastectomy in England as indicated by data from 2002 to 2011. The research was a retrospective analysis of statistics drawn from hospital episodes. It is noted by the researchers that for healthy women who are at high risk of developing breast cancer chances are there that a bilateral mastectomy might bring a considerable reduction in future risks. For women undergoing unilateral breast cancer, removal of the contralateral breast that is healthy in nature is a difficult process, and they are not able to justify it due to a number of factors mainly regarding emotional changes. The researchers examined trends in he statistics of women who considered undergoing bilateral mastectomy between the certain frame. The setting of the study was NHS hospital trusts in England. The participants were women aged between 18 and 80 years having undergone bilateral mastectomy within the time frame of 24 months after unilateral mastectomy. This was irrespective of breast cancer diagnosis. The study found out that the total number of women living in England who undergo bilateral mastectomy has nearly reached double in the last one decade. In a similar proportion, there has been an increase in the BM incidence who do not suffer from further breast cancer. For this population of women, the decision making process is marked by extreme complications. Chances are there that risk of facing death, need of the women for further treatment of cancer are the major factors that arise due  to the stage and biology of index cancer. Some women may have the preference for having a contralateral mastectomy for avoiding stress arising due to long-term surveillance as well as the risk of subsequent treatment of cancer. The strength of he article was that the information came from a national administrative database, making it a credible study. The database encompassed all NHS hospital admissions in which women were identified as having a mastectomy. However, the databases did not make out any difference between unilateral and bilateral cancer. The researchers were therefore not in the state of excluding women having a therapeutic bilateral mastectomy.  

Neto et al. (2012) studied the extent to which women undergoing mastectomy and breast reconstruction consider undertaking physical activity. The background to the study was that physical activity on a regular basis has often being recommended to prevent and treat coronary heart diseases, hypertension and diabetes mellitus. Apart from being a protective factor, acting as a defence against breast cancer, there is a positive relationship between survival and improved quality of life and physical activity. The aim of the study undertaken by the researchers was to undertake a proper assessment of the level of physical activity in women undergoing mastectomy with and without breast reconstruction. The study comprised of a total of 36 participants, divided into two groups. One group was made of patients who had undergone mastectomy without reconstruction of the breast while the other group was made of patients with reconstruction of breasts. The age of the patients was between 18 and 60 years. The participants were made to fill up the International Physical Activity Questionnaire. Statistical analysis revealed that for the group of women undergoing mastectomy with no breast reconstruction only 16.7% women were very active while 61.1% were active. It was highlighted by the research that adequate psychological and educational support have the potential to help the patients deal with their changing emotional and physical needs after breast cancer treatment. Such form of support would prove to be helpful in making the patients better equipped for dealing with the changes in the body. Women would be better able to combat losses due to cancer in terms of overall health and quality of life. This implies that polices emphasising on this aspect is needed urgently.

Offodile and Guo (2016) researched on disparate the British Breast Reconstruction Utilisation. The aim of the research was to understand whether the universal coverage is sufficient to ensure that the expanded care can be provided with optimal quality. The researchers intended to bring improvement in the understanding the common population has regarding the ability of the healthcare providers to consider delivery of optimal level care in the light on approaching an era of universal coverage. Two distinct vantage points were considered for the research. The first was the mandated coverage for immediate breast reconstruction (IBR) surgery that is considered as a microscopic surrogate for universal coverage on an overall basis. The second was the scrutiny of IBR utilisation rates in two different contemporary healthcare delivery models in the United Kingdom. These two contemporary systems were the private sector healthcare settings and the National Health Service trust. The literature review undertaken was carried out for measurement of IBR rates across private sector healthcare settings and public trusts in the United Kingdom. From the analysis of the results, it was found that the IBR rate was 17% for the public trust hospitals, whereas the IBR rate was 43% for the private sector. In the case of the trust hospital setting, failure was attributed to the enactment of the two government mandates in an attempt to bring enhancement of access to care. The mandates were put in place for increasing public’s access to cancer care. The failure was drastic as the capability of surgical practitioners to provide the patients with high-quality care was not augmented. 65% of women not receiving IBR had the viewpoint that they received the adequate information that was necessary to inform the major decisions to be taken. Moreover, only 46% of the population cohort put forward the idea belief that is a reconstructive surgeon was consulted after operation then it is more beneficial for the patient to take up the major decision. In this context, it was also found that private sector hospitals in the country were in a better position to deliver the IBR care. The probable reason for this was the provision of financial incentives given to the physicians and adequate infrastructures. The results of the study formed a basis for an immediate call for action to have a superior placement between any existing policy initiatives that have the aim of expanding care access to all sections of the society and consider changes in the prerogatives of the physicians. The ultimate outcomes would be optimised delivery of the care form that the policies mandate.

A recent work by Chowdhury et al. (2017) catered to the development of an individualised risk prediction model for contralateral breast cancer.  A growing tendency among the women who have been diagnosed with invasive breast cancer or ductal carcinoma to undergo contralateral prophylactic mastectomy has been observed so as to curb the risk of developing contralateral breast cancer that has been recognised to be medically unnecessary. This has been largely attributed to the overestimation of the contralateral breast cancer risk among the affected individuals due to lack of awareness and education. Results of the study suggested by virtue of acquiring data from two relevant data sources the risk factors that contributed to the emanation of contralateral breast cancer specifically targeted for women diagnosed with unilateral breast cancer. The factors that accounted for association for the development of contralateral breast cancer included age at first breast cancer diagnosis, familial history related to breast cancer, anti-estrogen therapy, breast density, and type of first breast cancer, high risk preneoplasia status along with estrogen receptor status in addition to the factor related to the age at first birth. The absolute risk concerning development of contralateral breast cancer over a given duration was projected through the utilization of the CBCRisk by means of combination of the relative risk estimates together with the relevant hazard rates. In the prospective model, the category meant for the age at first birth variable was combined with nulliparous and <30 age categories as their estimated relative risks were similar.  Thus the study has immense potentials in terms of counseling for breast cancer patients through provision of customized and individualized contralateral breast cancer risk estimates. Thus the perceptions of the unilateral breast cancer patients may be regulated to a large extent through tentatively predicting their propensity to suffer from contralateral breast cancer thereby ameliorating the rates of unnecessary contralateral prophylactic mastectomy.

In the pre-surgery condition of mastectomy, the nurses are entrusted with the responsibilities of educating the potentially vulnerable women regarding the screening sessions for breast cancer in order to pursue early detection. Assistance for women to better understand the strengths and limitations associated with various screening modalities available in order to detect breast cancer at an early stage have been considered as the duty of the nurses. These often pose the nurses and other healthcare professionals into challenges that call for greater attention and intervention. The variations in the guidelines along with valid evidence and consequent recommendations have been provided in the work of Mahon (2012). The relative risk of developing breast cancer is considered crucial for detecting the appropriate breast cancer screening modality. The risk factor associated with the development of breast cancer has been attributed to factors like being nulliparous. Nulliparous women have been estimated to have three times increased the likelihood of suffering from malignancy in the breast in contrast to women who are not nulliparous. Among the various breast screening modalities, breast magnetic resonance imaging, breast self-examination, clinical breast examination, mammography have been suggested as the preferred methods. According to the proposition made by the American Cancer Society in conjunction with the National Comprehensive Cancer Network, digital mammography has been suggested for the younger women and those having dense breasts. Research has shown that the management of female patients who are under the increased threat of developing breast cancer due to known or suspected genetic predisposition such as in the BRCA1 or BRCA2 genes, prophylactic mastectomy has immense potential in terms of drastically reducing the risk of breast cancer. However many women expressing known hereditary risk are unwilling to resort to such surgical intervention or are unable to undertake such surgery. Thus the nursing intervention and management offered by means of prudent nursing education is recommended in order to make the patients aware and informed about the potential benefits, harms and limitations of undergoing such interventions depending upon the circumstances. The education has been suggested to be articulated and imparted by the nursing personnel in a comprehensive manner so that the patient is able to understand in a satisfactory manner with scopes of questioning. Hence effective patient education has the capability of providing holistic solutions to the brimming problems related to breast cancer. Apprehensions and doubts regarding the utilisation of the screening modalities might be very much effective in reducing the rates of incidences of breast cancer and subsequent aggressive interventions like mastectomy as extreme treatment modalities. The vulnerability of the nulliparous women must be particularly taken care of while providing education through professional and nursing assistance to avoid the need of performing mastectomy like aggressive treatments.

The work by Ager et al. (2016) conducted a systematic review considering both the qualitative as well as quantitative studies to explore patient reported factors along with the psychological variables that influence the decision of undergoing the contralateral prophylactic mastectomy (CPM) and satisfaction with respect to CPM in case of women afflicted by early stage breast cancer. The most common cited reason as per the retrieved information from diverse sources showed that primarily considered fear for breast cancer to undergo CPM. Cosmetic reasons that accounted for the secondary reason for undergoing CPM were attributed to the desire to have symmetry. Studies suggested in the majority of the cases women expressed their satisfaction with regards to the outcomes relevant to CPM. However, in certain cases, dissatisfaction was expressed from their parts resulting from adverse or diminished body image, poor cosmetic result and, ensuing complications, emotional problems, diminished sense of sexuality in addition to the dearth of education pertaining to alternative surveillance and efficacy of CPM intervention.  Concerns regarding the prospect for contracting breast cancer in future years have often been cited as the reason for evoking fear and anxiety among women that in turn leads to undergoing CPM among them. In other cases, the mere presumption of having breast cancer and recurrence in future have resulted in undergoing CPM among the vulnerable population. Thus as preventive measure, these women resorted to CPM. Another factor that essentially influenced the decision to undertake CPM has been linked to extension of life and improved survival in the potential patients where patients perceived the inevitable progression of contralateral breast cancer to ultimately result in death.

Further, the desire for breast symmetry among women provoked them to undertake CPM as a cosmetic intervention rather than medical intervention. Moreover, a vital highlight to these studies referred to the influences exerted by members such as family, friends and spouse to undertake the decision to have CPM. According to the findings, the role of the physicians and their corresponding recommendations for patients who are at high risk of developing CBC is crucial in this context, although discussions relevant to CBC have often been found to be patient initiated. The decision related to CPM has also been accompanied by the encouragement from the family and friends with maximum influence coming from the ones predisposed to cancer. Moreover, positive opinions in favour surgery from the spouse/partner often influenced the final decision of CPM in the patients. The psychological factors associated to the decision of CPM have been identified to be multiple. The factors included the higher perceived risk of breast cancer, greater degree of neuroticism in conjunction to the notion that cancer is caused by genetic/hormonal factors. Moreover, the surgical recommendations were recognised to be intricately linked to less decisional conflict and greater preference pertaining to the preference for a bilateral mastectomy. The degree of satisfaction and dissatisfaction among the vulnerable women varied depending upon certain circumstances. The tentative reasons for the perceived satisfaction associated with the decision of undergoing CPM have been aligned to peace of mind, satisfaction resulting from cosmetic interventions along with body image. Moreover, mitigation of the risk factors in addition to the decreased amount of problems with the procedure along with a sense of prevailing over cancer also contributed to the perceived satisfaction from CPM. Contrarily poorer outcomes of cosmetic surgery, complications, diminished sense of sexuality, adverse or diminished body image along with a dearth of education regarding the efficacy of CPM or other alternative modalities available were associated with the dissatisfaction or regret after CPM. Thus it is of utmost importance for the clinicians and the healthcare professionals to make the women aware of the possible strengths and limitations of CPM thereby enabling them to make an informed decision regarding CPM in keeping with their values and preferences. More education and awareness is required in this respect to addressing the issue holistically.

A recent study by Glassey  et al. (2016) carried out in the form of literature review focused on the decision making, psychological wellbeing along with psychosocial outcomes in case of high risk women who opted for bilateral prophylactic mastectomy (BPM). The findings of the research brought to the forefront both the positive as well as negative outcomes linked to the psychological outcomes in response to preventative mastectomy. Alleviation of anxiety has been attributed as positive outcome of preventive mastectomy while negative outcomes have been attributed to impaired body image and sexuality. The psychological as well as the psychosocial outcomes in case of women who chose to undertake the BPM with specific emphasis laid upon the younger women aged less than 40 years have been extensively studied. The process of decision making as reported in the findings has often been attributed to the notion of having irrational fear in addition to accounting for the personal history, familial history as well as personality of the women who will be undergoing BPM. Instances related to the generation of excessive distress due to the diagnosis of cancer in the family are likely to impact the decision to undergo BPM amongst the prospective women. The genetic testing relevant to the BRCA1/2 mutation often culminates in inconclusive interpretations pertaining to the risk of developing breast cancer that leads to differential decision making in case of women who are at high risk of developing breast cancer alongside younger women who opt for BPM as preventive strategy to mitigate the condition. Moreover the overestimation of the risks of developing breast cancer has also been attributed to the decision of undergoing BPM both in pre and post surgery conditions. Another important insight provided in this study highlights on the issue of psychological wellbeing; anxiety and cancer related worry in case of the high risk women. the level of distress and anxiety are found to be greater prior to BPM that further underwent drastic decrease following BPM. Minimal levels of psychological and emotional distress have been further reported in case of women who underwent BPM devoid of any complications. Further, evidences have suggested that women who underwent regular screening experienced less psychological distress compared to those who did not have the provision for undergoing screening procedures prior to undergoing BPM.

Psychological consultation before the undertaking of CPM or BPm has been considered crucial to provide assistance for decision making apart from preparing the patients for the appropriate surgery. The reasons behind such propositions may be attributed considering the fact that these high risk women encounter difficulties and issues with regards to decision making, body image, risk perception, sexuality and psychological wellbeing. Altered negative perception of body image is also found to occur in case of women who have already undergone BPM that in turn renders negative influence on the woman’s sex life. The practicalities associated with conducting the surgery has been found to be explained in case of the high risk women although lack of information is evident concerning their perceptions of their wellbeing in post-surgery condition. The lack of information about the potential advantages and limitations pertaining to the issue of undergoing mastectomy among the high risk women has aroused confusion and considerable negative perceptions. Therefore, psychological consultation prior to surgery and appropriate recommendations from the physicians will help to better tackle the situation. The study has set in an important implication that the scenario in case of the younger women need to be investigated in details with known germline mutation and those having a strong family history of breast cancer. The variable needs and increased rates of breast cancer incidences among young women thus call for greater attention and insight.

According to the article published by the author by Arroyo and Lopez in the year 2011, it was found that the besides physical changes, a psychological impact also affects the unmarried women. Although the concept of psychological pain remains covered under the fear of the disease and its chances of reappearance, it affects the mental health of such individual to a great extent. This first affects the corporal imaginary of a particular individual which can be described as the mental image that every woman holds about her own body. This is often linked with intersubjectivity. She becomes extremely concerned about herself image as well as the perceptions that others hold about her body now. The researchers have also found that the body image is also linked with the concept of self-appraisal that instils confidence within her.

The researchers have also conducted studies where it was shown that most women consider their breast to be an essential component of erotica which imparts value to a women’s confidence. This is so said mainly because it has been admitted by them that removal of such a worthy part of their body makes them feel undesirable which affects self-confidence. They seem to get involved in a feeling of imaginary incompleteness that makes them to hide the situation not only from the society but also from self. Moreover, they also suggest that lost of such an important part of their body also makes them suffer from inferiority complex where a women undergone mastectomy considers them not worthy enough to be desired or loved on the basis of physical beauty. Moreover the effects of mastectomy also affects the sensitive bonding that exist between an unmarried couples where most women suggest that this might lead the male counterpart to lose interest in spite of comforting the female counterpart about the huge cancer struggle she had faced.

Often the concept of desirability is the mostly highlighted one where the field of masculinity and femininity and also the domain of the games of attraction between male and females are concerned. The femininity of the women is based on the attractiveness which they possess for the main and any alteration in the physical appearance that affects the attractiveness is perceived by the women like losing breasts makes her feel disfigured. According to her, her femininity weakens that affects her intensively.

However the idea about mastectomy is not the same in every individual. According to Hoskins and Greene (2012), a large number of women usually assume the risk-reducing bilateral mastectomy to be a better option in comparison to their alternative risk management options. The main reason for accepting the surgical procedure of removal of breasts although difficult is accepted by them for they feel it is better to feel safe and they believe that it can be possible by sidestepping potentially devastating outcomes. Researchers suggest that it might be mainly due to the avoidance of stressful and costly high risk screening, chemotherapy and also radiation. Often family members pay a great role in making the patient’s acceptance of the surgical procedure where the patients also believes it to be a better initiative to keep loved ones away from the challenges of cancer diagnosis. Often the reason for acceptance of surgical procedure is to reduce screening fatigue, encouragement from loved ones and also the urgency to put high risk period behind. For such women, the changes in physical appearance rarely becomes a source of concern as their support from loved ones does not make them feel sad about transformations in their body. Often their past experiences of a close person like mother or sister who suffered from a similar experience and has lost lives, influence their perception of risk and lead them to take effective action. For such patients, value of saving lives rather than physical changes seem to be more important. Certain women with very strong perspectives have described that it s indeed important for them to minimize the sense of uncertainty surrounding their risks rather than being physically desirable to others.

When patients were interviewed about their perceptions and fear about the losing of important components in their lives after surgery like pain as well as changes in body image or even sexuality, inability to breastfeed when they conceive or others, they chose to undergo surgical procedure.  This is because they commented that taking such decision seemed a better alternative to them rather than living with the fear and anxiety about when breast cancer may become uncontrollable and take upon their lives. They have more dependency on screening methods after surgery than living with uncertainties. Therefore one can easily portray here that not all young women perceive mastectomy as a loss of quality life due to physical transformations. They believe that surgical procedures reduce their stresses over cancer risk and do not affect the quality time, consciousness and energy making them free to be more available for their partners and other relatives. Therefore a large number of women of the mentioned cohort experience positive physiological outcomes along with high rates of satisfaction, reductions in anxiety, low levels of regret as well as healthy levels of psychosocial functioning long term. This article also stated that the challenges faced by the young women after surgical procedures will be of very little effect if partners, families and other relevant family health history modify her outlook towards the entire importance of saving life rather than being desirable. This will in turn have very little effect on her mental health after surgery where she will be confident about her decisions and about herself.

Sivell et al. in the year 2013 had published the paper which had provided greater clarity on the feelings and the decisions that women take when they are in the early phases of detection of breast cancer. The researchers have collected information about the various factors that decide whether a patient would go for mastectomy or they would go for breast conservation surgery. It had been quite interesting to see the various factors that have been depicted by the vulnerable women who were diagnosed with breast cancer. The factors are much different from each other and often reflect the psychological complications practised by each individual which are quite different from the other. The women who chose Breast conservation surgery (BCS) over mastectomy mainly pointed the fact that they would feel less feminine with the later surgery that prevented them to take it. Again, women who chose mastectomy over BCS suggested that removal of their breasts will have very little effects on their sex lives and therefore saving their lives and being safe from cancer is their primary motive.

People opting for BCS also suggested that they placed greater influence on body image and also on sexuality which in turn influenced their decision making ability. They also suggested that BCS would help them to conserve their femininity, sexuality and physical appearance. It was also found that the women who sought for BCS suggested that they were influenced by their partner’s want for opting for BCS whereas those who chose mastectomy suggested that they were influenced by their breast surgeon. It was noticed by the researchers that the social referents were found to be favouring the respondent’s own personal performance and sometimes the referents suggestions helped her to confirm a particular decision. In most of the cases, it was seen that partners were mainly seen to select the pro-BCS method rather than mastectomy. This automatically helped the women to understand the partner’s preferences and understood the importance of her body image in order to sustain the desirability of her femininity. However, there were also cases where the women’s own perception of their life being in danger due to cancer made them takes the decision of mastectomy that overrides the perceptions of their breast surgeons or partners. The negative effects associated with radiation therapy in BCS technique also forced many of them to take the concern of mastectomy over BCS.

Discussion 

From the above literature review, it can be stated that the psychological impact of breast cancer and mastectomy on women, specially young nulliparous women have been documented in details in existing literature. Loss of breast in women has a strong connection with negative influence on sexual well-being, emotional loss and loss of confidence. Moreover, there is also a significant dissatisfaction regarding own appearance. The negative impact that mastectomy has young women has been widely recognised as the patients have different potential options for retaining a breast after the initial surgery has been done. The present study revealed the women’s account of the impact of mastectomy of them and the support and care they require post-surgery. Research indicated that mastectomy has a negative impact on the women's body as it proves to be a threat to the sense of worth and desirability. The impact is also child bearing ability, and this is more significant for nulliparous women.

One can come to a conclusion that body image, femininity and sexuality are the main concerns that often results in patients to avoid the mastectomy surgical procedures. A female undergoing mastectomy due to her breast cancer often faces severe depression and anxiety as she loses self-confidence and her self-image completely crashes down. This is mainly because they believe that their physical attractiveness and their desirability would get affected. Her belief of loss of femininity makes her feel less desirable for others and in turn, make her develop depression and anxiety which leads her to regret on her decision. However, different mentalities of loved one like family members or partners often influence the decision of women and also tend to make her understand about the value of life rather than physical beauty (Holland, Archer and Montague 2016). It must be noted perspectives of partners and family members are not always the same and thereby may impact on then physical and mental stability of the patients. However there are many women have strength to overcome the issues if femininity as they value the safety of lives more than physical attributes and do not regret over their decisions, rather their main motive lies in the fact to relieve them form the stresses of danger from cancer (Rubin and Tanenbaum 2011).

Neuburger et al. (2013) have indicated that a relationship between breast surgery and sense of abnormality. The researchers had explored that there lies a connection between the sense of abnormality after breast surgery and the impacts of physical appearance. This opinion is in alignment with the suggestion of Sabino Neto et al. (2012) who state that women undergoing surgery relate their mental and physical status to the ability to carry out daily activities, their physical appearance, their ability to adapt to changes for adjusting to a new life and health status. Mastectomy, therefore, presents the patients with an emotional turmoil that hampers the sense of normality on the emotional ground and the theory of self-image and body image are interlinked when it comes to drastic changes presented by mastectomy. The literature undertaking a comparison between the impact of breast surgery on mental health and body image among nulliparous women might be yielding conflicting results depending on the population selected. Body consciousness when objectified might be a contributing factor influencing the well-being of the survivors. Body image is often the sense of self-reflecting mental presentation. An integral component of self-representation, body image links social and cultural beliefs with health practices (Lewis-Smith 2015).

The aim of the present review was to examine the impact of mastectomy on the young women aged between 24-45 years in United kingdom. The analysis yields the result that the impact on women is mostly negative. Cancer-related depression and body image are the two most crucial factors for bringing about changes in the lives of the patients. Nursing management concepts are pivotal for delivering care to patients and was, therefore, a part of the research objectives. Emotional support and encouragement have been found to be at the core of management care given to women undergoing a mastectomy. Mediated and direct relationship prevails between patient characteristics and care delivery. The third objective was to highlight the policies in UK for patient management after mastectomy. The NHS has contributed towards an early-discharge framework suitable for delivering care to patients. These policies have been formed after the consultation with patients and taken into consideration their plight and needs of care and support. However, further improvements are needed in this regard that emphasises on the changes in the needs of the patient against the evolving heath care practices. This is only possible when there is the scope of research undertaken based on gaps in existing literature. Evidence-based policies and reforms would be necessary for bringing about the up gradation in the way mastectomy are taken care of in the country (Sivell et al. 2013).

The findings of the present literature review are novel findings that highlight the issue of changes brought about by mastectomy from medical as well as socio-cultural point of view. These findings have major implication for future research. According to Glassey et al. (2016) observing and examining levels of consciousness in patients after the surgery and removal of breasts is to be made a priority for changing the manner in which care is given to the patients in healthcare settings. Interventions seeking a reduction of body surveillance and body shame are always critical. This critical and complex aspect is the underlying principle of care delivery. Providing systematic evaluation and assessment for survivors’ body consciousness promises to be helpful. Psychological consultations aim at collaborating patients with care professionals for the establishment of a standard procedure of operation. Moreover, counselors may be playing a role in encouraging women who target further mastectomy in cases of successive detection of breast cancer. In addition, routinely held consultations with women undergoing the surgery would highlight the perception they have regarding their body. Strategies for counselling are to be based on the significance breasts hold for the patients. Finding clarity of the women’s perceptions would raise the awareness level of the counsellors (Ager et al. 2016). Mahon (2012) have indicated that for bringing major changes in the way a patient is handled, the focus is also to be given to health professionals. For example, in a certain study, it was found that physicians had a key role in making an influence on the decisions of the patients after mastectomy. Sinc nulliparous women have the concern of child bearing embedded in their decisions in social life, consultation and advice of physicians remarkably bring positive impact on the lives of the patients. The suggestion given out regarding maintaining appearance and body consciousness are beneficial. Healthcare providers are to reflect on presentation of post-mastectomy alternatives so that there might be the development of interventions aimed at increasing body image and gender awareness among health providers.

Conclusion and recommendation

For healthcare professionals to plan and implement treatment pathways in a patient-centric manner, it is crucial to understand the association of emotional well-being of patients and mastectomy. The existing literature on the research topic is not sufficient to highlight the concern in UK. This is to be considered as a chief omission in the context that there is high survival rate of breast cancer patients who are young and fall under the age group of 24-45 years. Though the present research has brought into focus that mastectomy might be experienced in diversified ways, mostly complex, further research is required in this context.

The above literature review forms the basis for some key implications for health care professionals who play a major role in the process of caring for patients undergoing a mastectomy. Though some women have a positive feeling after undergoing a mastectomy, the proportion is relatively small as compared to women who have a negative feeling about undergoing a mastectomy. This section of the population may relatively feel negative about their surgery and changes in their body. They develop a certain hatred towards the body image they develop after mastectomy and benefit hugely from any form of additional support given for enabling them to accept the way their body has changed. Face-to-face support is highly recommended in this regard as the patient would be better able to come in terms with the body changes. The different healthcare organisations must offer informative programs addressing women suffering breast cancer and at risk of undergoing mastectomy or already undergone a mastectomy. Such programs providing information to patients would be the strongest form of support for the development of well-being of the individuals. The local course also needs to support communication between healthcare professionals and patients so that a suitable therapeutic relationship can be established between the two parties.

Physical changes are the major concerns for patients undergoing a mastectomy. Post-mastectomy treatment and interventions must ensure that the healthcare professionals, including nurses, discuss these interventions in a relationship with choices of sexual relationships and marriage in case of nulliparous women. Younger women may be feeling positive about their bodies and may neglect any negative impact of the scars. Nurses must therefore not have the assumption that the patients have a negative feeling about their body image. There is a degree of variability in the feelings and experiences of the women regarding their bodies. It is crucial to listen to the concerns of the women and their individual’s experiences and understand them. This would enable a proper balance between negatives and positives in the lives of the women. 

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