Breast cancer is prevalent worldwide (World Health Organization, 2010); is considered the top malignancy among the women (Saraswathi, Suzanna, Ho & Wong 2005). In Singapore, 1 out of 17 women acquires breast cancer, and it has highest incident rate among women aged 50 to 59 (Health Promotion Board, 2010 and Tey & Lee, 2008). Often, the patient and/or the husband undergo major adjustment, in order to conquer the threats of malignancy physically and psychologically. Because of the nature of malignancy and tumour location, mastectomy is usually the recommended treatment (Holly, Kennedy, Taylor & Beedie, 2003). Yet the idea of mastectomy is unwelcomed by many patients, as the removal of the breast means removing an important symbolism of femininity as well (Bredin, 1999). This thus inevitably causes them to suffer from some psychological disturbances due to the change of body image. Consequently, the partner may also be mentally affected due to the responses from the wife (Sandham & Harcourt, 2006). Hence, the process of recovery is made more challenging with the emotional distresses, interfere the patient from returning to the routine lifestyle.
Because of high incidence, this has brought about arguments which highlight the aroused psychological impacts after mastectomy. Therefore, in this paper, I would focus on psychological concerns and reactions of patients with mastectomy, especially those who have undergone radical mastectomy which is the removal of the whole breast, including the surrounding lymph nodes and muscles (Richman & Grose, 2010). Moreover, some reactions encountered by the partners and current interventions which could assist the patients and/or the partner are discussed, thus promoting better psychological adjustment.
Every woman perceives the significance of the breast differently; the loss of breast can result in reactions that vary among them. It is being studied that post-mastectomy patients exhibit high emotional distress (Kornblith & Ligibel, 2003). Significant concerns mentioned include feeling of depressed with their situation due to the breasts being removed, anxiety over cancer recurrence, and embarrassments with the image of incompleteness. Moreover, diminished of sexual functioning is also highlighted in the study. To a certain extent, women claims that sexual enjoyment seems to decline after the operation. Kornblith and Ligibel (2003) explained this phenomenon due to change in the patients’ perception towards themselves. The loss of sexual pleasure also arises because absence of the breast creates insensitivity during intimacy, thus interfering with sexual intercourse. It is commented that patients with breast conserving surgeries done, exhibit lower stress than post-mastectomy patients, but there is no extensive account of figures accompanied.
Similar findings with more detailed explanation by Bredin (1999) also supported that patients often verbalised feeling depressed over the altered figures, and are troubled upon seeing own reflections. Some may even progress to the extent of disliking the look of their bodies, resulting in poor body perceptions. In the article, some also reported the effects of breast loss on social identity. For instance, a lady is fearful of allowing the husband to touch her chest, claiming that she is afraid that the husband might experience a different sensation that he used to experience. Deceased intimacy between the patients and spouses could jeopardise the relationships and induce stress to the husbands, but it is not elaborated in the journal. Avci, Okanli, Karabulutlu & Bilgili (2009), also stated that some husbands are reluctant to touch the operated site, but it does not provide an explanation for the behaviours, partly because the research does not recruit the participation of the husbands. On the contrary, Kornblith and Ligibel (2003) give an account of the problems that the husbands may face. These include dissatisfaction with the relationship after mastectomy and decrease interaction between the couples as the husbands are uncertain about what to say. These behaviours made the wives feel isolated and hopeless; they have difficulties seeking back the pleasant relationships which they used to have. Nonetheless, Sandham’s and Harcourt’s (2006) study of the partners whose wives have had mastectomy, demonstrates that partners play a vital role in prevent maladjustment. Their concerns and supports are not only necessary for the wives to cope with the grief of breast loss, it can provide adaptation for the partners as they may handle the stressors together.
Karabulut and Erci (2009) provide the details that possibility of divorce increases after mastectomy, as the husbands’ attitude and expectation of the wives change, thinking they are less attractive. These eventually results in more maladaptive behaviours of the patients as they can achieve their desired self image, especially if they are young and have physical beauty expectations (Karabulut & Erci, 2009 and Holly et al., 2003). Nonetheless, risk factors of emotional instability are not greatly discussed by the journal.
Crompvoets’s (2005) study aids in the understanding of femininity which women associated with the breast. It is explained that the presence of breasts ties with the femininity and provides sense of physical attractiveness, by sharing some stories of patients. It has been accounted that without breast, women feel “physically handicapped” and feel they have evolved to somebody who seems distant to their usual self (Crompvoet, 2005, p.79). A different in this article is that the effectiveness of breast reconstruction is also explored, and case-studies of the patients who received the treatment are also shared, mentioning regain of femininity which is robbed by mastectomy. Positive feedbacks of reconstruction are identified by them, empowering them for better adjustment and overcome poor body-image.
Findings by Harcourt and Rumsey (2001) have reflected another psychological adaptation is observed in patients during breast reconstruction. Self-esteem is restored and improvement of the perception of disfigurement is achieved with the intervention. Moreover, a comparison result is showed if reconstruction treatment could initiate immediately after mastectomy. However, the authors contradict the use of prosthesis which enables the concealment of operative area, is explained by the Mahon & Casey (2003) as a mean to improve quality of life. They mentioned that wearing prosthesis is inconvenient and serves a reminder for the patients about the traumatising event, thus more patients would prefer surgical reconstruction to prosthesis (Harcourt & Rumsey, 2001).
The literatures provide sufficient discussion on the psychological impacts after mastectomy. Due to the altered body image, various psychological concerns are stimulated, impairing the well-being of the patient, and the relationship with the husband may weakened. Reconstruction interventions are effective in restoring femininity, and are being engaged by many patients.
Relevance to nursing practice
The nurse can alley the tension of the couple by providing sufficient information preoperatively, so that they are mentally prepared, thus minimising postoperative stress (Richman & Grose, 2010). Too much information can be overwhelming for patient, thus it is more appropriate to assess and address immediate issues that the couple is concerned. Alternatively, handouts could be provided to allow them to refer when necessary (Morris, 1979). These preparations warrants effective outcome for realistic goals and undertakes a patient-centred approach in delivering care (Denton, 1996). These in turn enhance postoperative care and sharing of thoughts, when the couple is comfortable with the nurse and feel less intimidated if the barrier of formality is removed. In other word, establish rapport with the couples, facilitating explicit discussion so that sufficient assistance is supplied (Harmer, 2004).
During the postoperative period, the nurse may face a dilemma to decide whether the patient should be asked to view wound. According to Denton (1996), assessment of patient allows determination of the psychological aspects. If patient is susceptible to serious emotional distress and is in unstable mood, probably she is not ready to observe the scar. Gradually, encourage patient to view the altered figure through a small mirror before progressing to full-length mirror to avoid sudden emotional breakdown (Denton, 1996). Husband could also be allowed to look at the site, as his presence is believed to be coping measure for patient. At the same time, he may have better control over the situation if he is aware of the wife’s condition and being participating in care (Sandham & Harcourt, 2006).
Opportunity should be created to allow interaction between the couple. By encouraging them to converse, certain issues could be resolved, and fear of uncertainty may also be diminished as misunderstandings or misconceptions are clarified (US National Institute of Health: National Cancer Institute, 1990). As such, educate the husband so that he would not be afraid to touch the wife, worrying that he may hurt her. Though this may be a small gesture, it reassures the wife for the husband’s understanding, so that the wife would not misinterpret the behaviour as a form of rejection. Often, counselling ought to involve both patient and spouse, hence diminishing anxiety through mutual knowledge and cooperation (Sarawathi, Suzanna, Ho & Wong, 2009).
When patients are keen for breast reconstruction, relate the concerns to the team doctors, so that they can refer patient to plastic surgeon, allowing discussion for desired cosmetic outcome (Greifzu, 1986). Alternative measure of prosthesis can also be offered, so that patient is informed of the available measure to improve self image (Mahon & Casey, 2003).
Social support groups have shown to be effective in empowering patient (Skrzypulec, Tobor, Drosdzol & Nowosielski, 2008). Thus introduce available programme to the couple, enhancing sharing of coping strategies and assist one another to overcome the challenges of accepting themselves and establishing functioning role in the family again.
Recommendations for future research
It is mentioned that breast cancer is a “couple’s ordeal” (Sandham & Harcourt, 2006, p.67), it is thus valuable to exploring the couples’ reactions together, rather than just including the patient or the spouse as research subjects. It is believed that this can generate useful results, making help available if problem is identified in the process. This in turn may serves as valuable information for new patients, and enables them to learn from the real examples, hence preventing similar problem from occurring.
Since mastectomy is common in treating breast cancer, it should be an area which is well research on (Skrzypulec et al., 2007). However, in Asia, it can be a challenge to get participates in breast cancer research due to cultural factors which may hinder active involvements (Tan, 2009). Thus, engaging more studies on Asia, especially an urbanised city like Singapore, could establish significant data that are useful in creating awareness and serves as a form of support to current patients by grouping them together.
Being a method that offers higher survival rate, mastectomy imposes mutilating emotions which affects patients’ well being. Due to the sudden loss of femininity, patients are vulnerable to elicit negative reactions in response to the altered image. These emotions inevitably contribute to the stressors that may be encountered by the spouses, eventually result in unpleasant relationships. In order to support them in undergoing such a dreadful period, supports from the multidisciplinary team are important, especially nurses could help in playing an active role. Hence, the nurses’ duties help to facilitate communication between the couples, and also convey concerns to other disciplines, thereby rendering resolutions to improve quality of life.