BREAST CANCER
Breast cancer is the most frequent cancer among women, impacting over 1.5 million women each year (500.000 in Europe), and also causes the greatest number of cancer-related deaths among women. In 2016, 570,000 women died from breast cancer – that is approximately 15% of all cancer deaths among women. While breast cancer rates are higher among women in more developed regions, rates are increasing in nearly every region globally.
Breast cancer is a disease that has a huge social impact due to the high number of cases, the psychological implications, the relationships and family life, the consequences on the world of work.
There are different biological and environmental factors as: age, having a family history of breast cancer, diet, some hormonal treatments, lifestyles in general.
Mammography screening has changed, over the past 30 years around world, the diagnostic and therapeutic approach to this disease, reducing the number of deaths from breast cancer by up to 30%. It allows to find many more tumors because many more women are involved in prevention programs; it makes most of the tumors detected much more treatable because diagnosed at a very early stage; it has pushed both surgical and medical oncological therapy to find a less invasive and disabling approaches, proportionated to the size of the tumor.
Ultimately, we are witnessing for many years now an evolution in the diagnosis and treatment that will surely lead to a progressively decrease of the mortality rate for this tumor.
Prof. Adriana Bonifacino
Head of Diagnosis and Therapy Unit in Senology
U.O.C. Oncologia
A.O. Sant’Andrea – Roma
Sapienza Università di Roma
EPIDEMIOLOGY
Breast cancer is the most prevalent form of cancer in women across EU countries. One in nine women will develop breast cancer at some point in their life and one in thirty will die from the disease. Risk factors that increase a person’s chance of getting this disease include age, family history of breast cancer, genetic predisposition, reproductive factors, oestrogen replacement therapy, and lifestyles-related factors including obesity, physical inactivity, diet, and alcohol consumption.
Breast cancer survival is increased with early detection and most EU countries have adopted breast cancer
screening programmes. The periodicity and target groups vary across countries however (OECD, 2013). Due to recent progress in treatment outcomes and concerns about false positive results, over-diagnosis and overtreatment, breast cancer screening recommendations have been re-evaluated in recent years. Based on recent research findings, WHO recommends organised population-based mammography screening (WHO, 2014).
Screening rates range from 23% in the Slovak Republic to over 80% in Portugal, Denmark, Finland and Slovenia in 2014. The screening coverage increased substantially among countries with low rates a decade ago, including Poland, the Czech Republic and Lithuania which have more than doubled their screening rates. Overall rates across the European Union rose from 54% to 63%. A number of countries did report lower rates in 2014 than in 2004 including Greece, Italy, Luxembourg, Austria, the Netherlands and Finland.
Breast cancer survival reflects early diagnosis as well as improved treatments. All EU countries have attained five-year relative breast cancer survival of 80% except Estonia and Poland. Poland also shows the lowest relative survival for cervical and colorectal cancers. These low rates are correlated with limited care
access and relatively fewer numbers of cancer care centres and radiotherapy facilities (OECD, 2013).
Over the last decade, the five-year relative breast cancer survival has improved across all EU countries and rates have increased from 79% to 84% on average between 2003 and 2013. This increase has been particularly noticeable in Eastern Europe where Estonia, the Czech Republic and Latvia have increased rates by 11, 9 and 8 points respectively. This improvement may be related to strengthening of cancer care governance in these countries. For instance, the Czech Republic intensified its effort to detect breast cancer
patients early through the introduction of screening programme in 2002 and implemented a National Cancer Control Programme in 2005 to improve the quality of cancer care and cancer survival. This programme focused notably on increased population coverage and access to specialized services (OECD, 2013; OECD, 2014).
Mortality rates have declined in most EU countries over the past decade, with the EU average falling from 37.3 per 100 000 women in 2003 to 33.2 in 2013. These reductions reflect improvements in breast cancer
detection and treatment. Significant improvements were seen in both the Czech Republic and Denmark with declines of over 24% during this period. A small number of countries reported increased rates of mortality in 2013, including Poland, Bulgaria, Latvia and the Slovak Republic.
Source: Health at a Glance 2017. OECD Indicators http://dx.doi.org/10.1787/health_glance-2017-en
REHABILITATION
The breast cancer treatments are over. Now what?
When talking about cancer usually problems related to prevention, diagnosis and therapy attracts the discussions as the attention of the media and the majority of the available – human and financial – resources.
But are these the only problems of the complex oncological disease, especially for patients who live this experience in first person? Once the treatment cycle is over, is it possible to get back to a normal life?
From the experiences we have acquired in about twenty years in the oncological rehabilitation field, we are more and more convinced that the problems, the big problems, the ones that condition patients’ life, arise right when the so-called official treatments, surgical therapy, chemo and radiotherapy are over. Once completed these treatments, generally patients resume their working activities, family management, relationships with the partner that also involve a particular intimate and sexual sphere; in short, we get back to life!!
We believe that “BACK TO LIFE” sentence fits more to this context rather than the general term – used by both the scientific community and the general population – “survivor”. The term “survivor” does not express the inner process a person after a disease has to go through; the person wants to get back to life and not survive. Two different concepts, two different approaches to this very delicate phase.
Those who live in this particular situation should not be afraid or reluctant to ask for help because it is essential to rely on people who, by human capacity and professional experience, can offer and assure such help.
For many years we have been fighting on the recognition of the importance of Oncological Rehabilitation as a next stage to the oncological therapies just to offer support, a help from the physical and psychological point of view to patients who present disabilities resulting from cancer pathology in all various stages of the disease.
The rehabilitation environment is the most suitable to take care of patients who have these disabilities, understood in the broadest sense of the term, deriving from the oncological pathology, therefore both physical and psycho-relational disabilities that limit and strongly condition their quality of life.
The oncological rehabilitation is a team work; different professionals get involved and engaged according to the needs of the patient. The team work ensures the sharing of knowledge and skills for the specific rehabilitation goal (Individual Rehabilitation Project) developed for each patient.
The rehabilitative team key figures are the physician experienced in this discipline and who therefore has oncological and rehabilitative skills, who will perform the initial assessment of the patient – to make emerge the rehabilitation problems to be addressed – and a properly trained physiotherapist who will take care of the patient and that after a specific assessment and formulation of the Individual Rehabilitation Project will start the treatment with the different rehabilitation techniques necessary and specific for that patient.
For example, in the case of a lymphedema – a condition of localized fluid retention and tissue swelling of the upper limbs caused by a compromised lymphatic system – different treatments can be done: manual lymphatic drainage, elastocompressive bandage, pressure therapy, shock waves, lymphotaping, prescription and testing of an elastic brace. However, these interventions should not only be limited to the upper limbs but should consider the whole person in a holistic approach to the patient. This is the reason why, in the Rehabilitation Team there are always a Psychologist and a Nutritionist.
What are the problems that can be faced in an oncological rehabilitation path?
In addition to lymphedema, as mentioned above, the other most frequent disabilities are shoulder joints problems, scar tissues due to surgery and radiotherapy, neurological complications such as the winged scapula, postural alterations, the consequences of reconstructive surgery (mobilization of the limb during expander filling, encapsulation of the breast implant, secondary alterations to the removal of muscle-cutaneous or cutaneous flaps), the overweight, very common especially after the cycle of chemotherapy.
Another important aspect addressed within a rehabilitation process is the patient’s Therapeutic Education, a relational communication process aimed at making understand and know all aspects of the disease and enhance the patient’s participation in the management of her disability, with a great attention to the adoption of particular lifestyles that now are recognized having a fundamental role in both primary and secondary prevention of oncological diseases.
Our rehabilitation protocol needs to include educational interventions aimed at supporting this aspect, proposing both a proper diet, but above all an adequate physical activity. This is a particularly important aspect that requires assessment and specific skills as not all physical activities are recommended for a patient suffering from cancer pathology; the physical conditions, may be different from person to person and above all extremely variable in relation to the severity of the disease and the stage of oncological treatments that are being undergone (chemo, radiotherapy) and to any possible outcomes and disabilities.
We, thus, refer to the Adapted Physical Activity (APA) and then, to the Adaptation Theory, in order to tailor a certain physical activity, appropriately selected, both in terms of equipment to be used, frequency and duration of the training sessions, intensity of the activity, environmental context, monitoring of the activity, surveillance of adverse effects etc … all aspects that have to be chosen and “adapted” by skilled and trained personnel. A physical activity carried out not in the correct way can cause serious damage.
The APA is indicated during the rehabilitation process to support it or at its completion to maintain the results achieved and – where necessary – to promote a healthy lifestyle.
But in the “after” of oncological therapies, we have to pay attention also to the so called “unconventional” therapies, which we underline in a clear and precise way cannot replace conventional cancer treatments, but that can help to recover the psycho-physical well-being during and after this particular experience.
Oncological Rehabilitation, Adapted Physical Activities and Unconventional Therapies can provide a concrete and valid support to patients with cancer pathology because we do not have to consider a patient as a survivor but as a person who has to get back to life and smile!
MD. Antonio Mander
Head of the Vascular and Oncological Rehabilitation Centres
C.A.R. e V.VOJTA Roma
Trainer at the Italian School of Nordic Walking
A.S.D SALUTE in MOVIMENTO
PSYCHO-ONCOLOGY
What is psycho-oncology?
Sometimes it is also referred to as psychosocial oncology or behavioural oncology because it deals with psychosocial and behavioural topics. The field is concerned both with the effects of cancer on a person’s psychological health as well as the social and behavioural factors that may affect the disease process of cancer and/or the remission of it.
It appeared in the United States in the ’70s and in Italy in the ‘80s and in 1985 the Italian Society of Psycho-oncology was founded.
The development of this discipline can be related to the cultural changes given by more information to patients, who are increasingly considered as protagonists of their personal care path. More informed patients who want to participate consciously in the choice of their treatments have shifted the attention on the psychological and social aspects of the oncology path.
Psycho-oncology develops, therefore, in a general framework of change of medicine that sees its purpose to offer patients a tailored treatment that takes into account not only the extent of the disease, but also of the person with her/his expectations, concerns and psychological needs.
Psycho-oncology is focused on the reactions to the specific event of the patient’s illness and to the psychological, social and behavioural variables that influence prevention, adherence to therapeutic treatments and quality of life.
Main factors of emotional distress
Numerous personal factors play a central role in determining the psychological distress of women who face breast cancer and who can benefit from specific interventions.
Some of these of these factors are for example:
– Changes of own body image
– Concerns about the consequences of medical treatments
– Changes in the current or future relations with the partner
– Concerns related to treatments that can cause consequences on fertility
– Concerns about own children and / or non-self-sufficient family members
– Concerns related to the temporary decrease of autonomy
– Concerns about the immediate and long-term future
– Previous negative family history of breast cancer
– Previous history of psychological distress or anxiety
– Sexuality disorders resulting from diagnosis or treatment
Why talking with a psycho-oncologist?
Cancer patients often do not talk about their suffering or talk about it without fully communicating it, assuming that it is normal to suffer in such situation. This is a misunderstanding that can negatively affect the quality of life and the ability to find emotional resources to cope with it.
Data from Italian and international studies indicate that between 30% and 40% of cancer patients suffer from significant levels of emotional distress, but less than 10% receive specialized intervention. This is of great concern because cancer changes people’s lives and has a strong impact on the existential, psychological and social levels. Sometimes, the help offered by doctors, nurses and relatives is enough to support the person in the process of adaptation. Other times, however, reactions of anxiety, demoralization, sleep problems, difficulties in sex, couple and family life exceed the cognitive and behavioral capacities of adaptation and in some cases, remain even beyond the completion of the therapies.
In these cases, a specialized support can be important to favour the best possible adaptation to the oncological path.
How is the psycho- logical intervention structured?
Psycho-oncological support consists of one or more individual or group interviews, centred on the reaction to the disease and / or to the treatment with the aim of relieving the emotional suffering of the patient and / or her family members. The services provided are:
– Psychological support
– Group psychotherapy
– Individual or couple counselling
– Consultations for family members in crisis situations
– Relaxation techniques
– Evaluations on the quality of life
– Psychological tests
– Distribution of informative material
MD. Anna Costantini
Responsible U.O.D. Psycho-oncology
A.O. Sant’Andrea Roma
Sapienza Università di Roma
Presidente S.I.P.O.
To know more about breast cancer, diagnosis and treatment options click here http://www.who.int/cancer/prevention/diagnosis-screening/breast-cancer/en/
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