THIS article endeavours to give an insight in to the daily happenings in the life of a Clinical Nurse Specialist in Breast Care at Cork University Hospital.
A little bit of history first...
The first mammogram performed in Cork was around 1982 at the South Infirmary Hospital and the breast service as we know it today evolved in Cork back in 1992.
The first breast clinic was established at South Infirmary Victoria under the clinical guidance of Mr John Kelly and Mr Denis Richardson. A number of years later, two further clinics were established at the CUH and Bon’s Secours Hospital.
In the early ’90s it was recognised from research that breast cancer as a disease should be managed by a multidisciplinary team in order to ensure improved outcomes.
The emotional and psychological impact of a breast cancer diagnosis was huge to these ladies then, as it is nowadays.
Unfortunately, back then the women had very little support. When the first breast care nurse specialist was appointed in Cork she was only the third in the country, after appointments in Galway and Dublin.
The biggest change/improvement in breast cancer care was the introduction of the multidisciplinary approach and the support of an identified breast care nurse specialist.
Roll on the years and following formation of the National Cancer Control Programme (NCCP) and the establishment of the National Breast Screening programme Breast Check, Cork now has a service based at CUH which assesses women with both benign and malignant outcomes.
Time has to be given to our benign patients also as they concerned until given a normal result.
We see about 6,000 new patient referrals, 9,000 return patients and perform 1500 biopsies per annum (2016).
We treat around 700 breast cancer patients per year at the Breast Check Unit and CUH.
All in a day’s work...
To move on and try to encompass the daily life a Breast Care Nurse specialist…
All good days at work start with a coffee and we are no different at CUH. Our day starts early at 7.30am so that coffee is very important.
Our day can be very varied in what we do, attending clinics, diagnosis consultations, arranging further tests and scans, post-op treatment plan consultations, wound care and ward visits.
We spend a large amount of our time dealing with phone queries, patients have our mobile numbers and we are a direct link for them post assessment or treatment for a breast problem.
We can often sort out issues without the need to return to the hospital.
Patients find the phone contact invaluable.
We deal with calls from GPs and public health nurses and family members on a daily basis also.
The Journey of a Breast
Women are referred to our breast service with a variety of breast problems Generally our day begins with a three to four hour triple assessment clinic which is consultant led, where a woman with a breast problem has:
Radiological assessment with mammogram +/- ultrasound
Pathology assessment with biopsy
As quite a number of the women are extremely anxious regarding the investigations and then the outcome, the Breast Care Nurse specialist will spend time explaining the process and how long they can expect to be waiting for results.
For women referred with breast pain, education regarding treatment with evening primrose oil is part of our brief.
General education regarding breast awareness is another area we discuss with ladies at the clinic.
Every Thursday morning the multi disciplinary group meet at 8am and discuss all women following biopsy, women for discussion post surgery to arrange their treatment plan, complicated cases, women with family history, or breast cancer genetic carriers.
The MDT group consists of: MDT coordinator, Breast Surgeons, Radiographers, Radiologists, Pathologists, Breast Care Nurse Specialists, Medical Oncologists, Oncology Liaison Nurse Specialists, Radiation Oncologists, Medical teams working with each discipline and Clinical trial teams.
Breast Cancer Diagnosis
At the end of clinic or outside of clinic hours is generally when we will set aside time to give patients a diagnosis of breast cancer.
There is nothing as valuable as delivering this diagnosis in a sensitive, calm manner and to allow as much time as possible for this.
Following discussion at the MDT meeting, an individual treatment plan for each woman is arranged.
All diagnoses are given by the woman’s breast surgical oncologist in the presence of a breast care nurse specialist.
Patients are encouraged to have a family member or significant other with them.
This diagnosis of breast cancer is an extremely difficult time for the patient and her family.
We explain the results, discuss the treatment plan, and arrange further appointments and tests as appropriate. All this is done in a clear manner and we are mindful of explaining it in non-medical language.
Most important is to give emotional support and again to allow as much time as the woman needs.
A diagnosis can take anything from an hour to three hours.
Treatment for Breast Cancer is not one model fits all. It is tailored to the woman’s cancer type/physical issues and; indeed patient preference. The plan is presented to her by her consultant and tweaked appropriately without deviating from curative intent.
Treatments can include a number of the following and in a variety of order: Surgery, Chemotherapy, Herceptin therapy, Radiotherapy, Hormonal therapy, +/- reconstructive surgery.
This is where the woman begins her breast cancer journey and her breast care nurse specialist will accompany her during this time, will support her and act as her advocate.
The diagnosis can stimulate many reactions, from shock, sadness, disbelief, to anger, and patients often describe it as a ‘roller coaster of events’.
It is extremely difficult to assimilate all the information given at the time of diagnosis and women often cannot hear any other word, only the word CANCER.
The breast care nurse specialist will meet the patient at a later time to reiterate the information given to her by her consultant and discuss the treatment plan for her.
This is too a good time to identify her needs at an emotional / psychological level and to also get to know the woman, her family needs / supports.
Our day then continues where we visit our patients who are in hospital for surgery either as a day case or as an inpatient. We give them post operative advice prior to discharge.
Our inpatients will require a number of the following depending on surgery type: wound care, drain care, pain management, fitting of prosthesis and bra, emotional / psychological support, referral to Arc House/ Daffodil Centre or Psycho-oncology service as needed.
Once a patient is discharged we are their link to the consultant/hospital and are in daily contact with them. We arrange their follow up for results and treatment plans going forward.
Every woman’s breast cancer journey can take a different route and may hit many crises, big and small. We try to make this journey as easy as possible for our patients and to help in any way possible.
Apart from looking after our breast cancer patients, the breast care nurse specialist consults with benign breast patients on a regular basis. These ladies too need to get results in a timely way and can often be quite anxious.
Breast care nurses liaise with breast cancer patients regarding the following: Immediate / delayed reconstruction, Radiotherapy, Hormonal therapy, side effects of treatment, ongoing psychological support and referral to other disciplines when necessary, advice with financial matters and referral to appropriate bodies for help, discussion with women with a family history or breast cancer genetic carriers, nipple tattooing post reconstruction, staff education, public education sessions for example Breast Awareness, Hormonal Therapies.
Above is a synopsis of the work of the Breast Care Nurse specialist at CUH.
I hope I have given an insight to our role.
We work as part of a team and have an excellent working relationship within that team and disciplines.
The Breast Service would not work for our patients without that relationship functioning as it does.
The Breast Patient and especially our Breast Cancer Patients are the centre of our working life.
Our advice to them is there is no right or wrong way to get through this, to stay as positive as possible and never be afraid to ask questions regarding their management. Over time we become close to our patients and look forward to our follow up with them.
We feel we have done a reasonable job when they re establish normal living and even forget their appointments!
It is a lovely career for any nurse wishing to specialise and we highly recommend it.
In order to cope with our job we do as much as we can for our ladies during our working day.
We have great fellow breast CNS colleagues whom we bounce worries, difficulties and stressful cases off — this is invaluable.
Above all we enjoy our Breast Care Nursing Career and hope we make a difference.
By Margaret Burke, Yvonne Bohane, Norma Dowling, Evelyn Farrissey, Mary O’Donoghue (Kerry) and Margaret Shanahan.