MEDICAL ENGLISH 4.docx

MEDICAL ENGLISH 4

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Living with breast cancer

Breast cancer is the major killer of women in the Western world. Despite enormous resources to research on breast cancer, we have not yet made a significant impact on the life expectancy of patients diagnosed with the disease. In the last 10 years, however, attitudes to breast cancer have changed. The on screening continues. Patients are demanding more and better information about their disease. Treatments have become less toxic and, increasingly, are taking into account not only the duration of survival, but the quality of that .

- Most treatments for breast cancer cause serious side-effects and physical , as well as psychological distress. Increasingly, patients are participating in the choice of their treatment options.

- I think in most Western countries there’s been a shift over the last decade towards more conservative forms of surgery for breast cancer; lumpectomy, wide local excisions and so forth.

This is due to a variety of things. Of course the pressures put upon doctors by many women’s groups, but also, data that’s started emerging from some important studies over the last ten years have shown that there is no difference in terms of survival between more radical surgery and conservative surgery with radiotherapy.

The problem though with local excision, conservative forms of surgery, is that recurrence is still quite high, local recurrence in this group is still quite high. About 20 percent of women treated by lumpectomy probably having a mastectomy and for some women that’s quite unacceptable. And so when given a choice, if they’re truly informed of all the various risks involved with the different procedures, quite a few will still actually prefer to mastectomy rather than lumpectomy. Another good reason for women sometimes preferring - although it seems rather , some women genuinely prefer to have a mastectomy - is to avoid radiotherapy.

Certainly it’s common in most Western countries now to always accompany with radiotherapy, and for some women this can be one of the most unpleasant aspects of treatment. Some people are very unhappy about the , the sensations of the conserved breast following radiotherapy and many women are very bothered by the enervating fatigue that one can experience following a course of radiotherapy.

- The availability of less toxic chemotherapy, effective hormone therapy and more antiemetics are making adjuvant treatment more acceptable.

- Chemotherapy always sets fear in the hearts of people the moment any doctor tries to mention it to them. But I think that again most studies that have been done over the last ten years in particular, the studies, have shown how important adjuvant chemotherapy is, particularly in the under 50s. There is an advantage to about 15 percent, to women under 50 who have cytotoxic chemotherapy. And the role of tamoxifen in the post-menopausal woman, hormonal adjuvant therapy is of course extremely important in preventing breast cancer in the contralateral breast and in the treated breast if it’s been conserved.

Although I think women are still extremely of chemotherapy, actually some of the regimens for breast cancer are not as toxic as many of the regimens that are given for other forms of cancer. That’s not to say these side-effects should be . For some women it is intolerable and they will fail to complete a course of treatment. But for others it’s usually not quite as bad as expected and of course with the of the new antiemetics we can at least prevent, to a certain extent, or at least ameliorate one of the worst aspects of chemotherapy which of course was nausea and vomiting.

- In theory, early detection should make it possible to treat earlier and achieve better results. Which populations should be screened? When and how should they be screened?

- Well this issue of who, when, how - as far as screening is concerned ¬- is a very one and causes a great deal of argument at every academic meeting you ever go to. If we can take the case of breast self- examination to start with, there’s actually little clear that women who examine regularly necessarily experience a reduction in the severity of their disease. One of the problems is that even those women who do examine themselves regularly, seem to in reporting symptoms they find for just as long as those women who never examine or very rarely and just accidentally find a lump.

Reasons women give for not doing it? Some are very uncertain about how to do it. Some just don’t like the idea of examining themselves. So you’ve got a lot of resistance to people doing it regularly and as I say little evidence to show that it makes a great of difference.

I mean the interesting thing here is how do you motivate people sufficiently to check their breasts, to go along and report symptoms and problems without inducing this anxiety that makes them so fearful that they don’t do anything? I think that’s the area that those of us interested in the psychological aspects of this disease are working on at the moment.

- Mammographic screening has also run into problems.

- As far as mammographic screening is concerned, well again there is a lot controversy about how often this should be done and which age groups it should be done for. In the UK, various were set up to initiate a national breast-screening program and it was decided after reviewing all the evidence available from various studies conducted in the US and Sweden and so forth, that the optimal age group for mammographic screening should be women above the age of 50 and under the age of 65, because it was that group that seemed to most benefit in terms of early detection of the disease. It’s hoped that, provided that group is screened once every three years, that we could reduce the mortality from breast cancer by 25 percent.

However there’s a there because it assumes that 70 percent of women eligible who are invited to come along for screening will accept and do that regularly. It’s very difficult sometimes to convince people that they should go along for regular examinations unless they have symptoms. The idea of prevention, prophylactic care, is still to many people. And if you have to give up things like money, organize time off work or people to look after other dependents for you, and you’re not even ill, it’s difficult in fact to , particularly some of the lower socioeconomic and educational groups to come along.

- Attitudes to breast cancer are changing at many levels. How have these changes affected the way oncologists treat patients?

- I think one of the big changes that’s occurred as far as oncologists are concerned is a that they have to actually give patients a great deal more information about what’s going on. And I think it’s of course that women do have information because it’s very hard for a woman these days to pick up a magazine or listen to a radio program that doesn’t contain something about breast cancer. So they’re that there are hundreds of treatments potentially available. So the doctor has got to offer some explanation as to why in their particular case he or she is recommending one treatment rather than another.

I think the other big change for oncologists is that they have got less toxic treatments to offer patients. Many of the chemotherapy from ten years ago were pretty horrible things to go through and at least they know now as well with the 5-HT 3 antagonists that they have got effective means of helping with the emesis that’s associated very often with chemo.

- Patients’ attitudes are also changing and increasingly they are their rights as consumers of health care.

- I think that one of the things that has changed is that women also are much more aware that they are a powerful lobby to improve things. I mean many of the changes that have have come about because of women making their voice heard, that they wanted more attention paid to some of the other areas of care that were being ignored, like the psychological aspects. In fact, I think sometimes now to the of other patients with cancer, because many of the other patients that an oncologist will see don’t have quite the same level of public sympathy and support, official channels of support that women with breast cancer have.

I think that part of anxiety reduction is access to adequate information, and certainly information has improved. It’s easier to access information, to get explanations about what’s going on. I think women, those who belong to the higher socioeconomic groups, certainly know that they can and actually they don’t have to accept the first treatment that is offered to them by somebody.

- Communication skills in dealing with patients are now recognized as a critical factor in helping patients to adjust.

- We’d got lots of evidence from studies we’ve done over the past ten years, in particular with women with breast cancer, showing that one of the most important influencing effective long-term adjustment to the disease and treatment was the communication skills of the original doctor who broke the bad news about the diagnosis and discussed the various treatment options available.

The Royal College of General Practitioners for example, certainly have made greater efforts to improve the communication skills training of GPs and a lot more is being thrown on their shoulders. I think increasingly with the care reforms in the UK over the last few years, a lot of the follow-up, routine follow-up of patients with cancer that might have previously taken place in the hospital will be devolved to general practitioners. So they’ve got to hone not only their own in terms of communication but also their own education about cancer and what information to give people.

The situation today

- Sadly, I think that for most women the diagnosis of breast cancer, well even actually the discovery of a breast lump comes as a horrible shock to them. It still does a great deal of fear and anxiety. And rightly so, I mean it’s still the biggest killer of Western women. One only has to look at the statistics to recognize that those fears are not totally . I think it’s a rather sad thing to admit that, despite the billions of pounds and dollars that have been spent on research, we’re not really doing very much to prevent the disease and the deaths from it. I mean I think people might be living slightly longer, but that could in fact be an that we pick up the disease earlier and therefore it might appear that they survive longer.

But the quality of that survival is actually the important here from the point of view of somebody like myself who works on the support issues that are important in breast cancer. And I think that we do have evidence that women perhaps are living better with their disease. I mean first of all the treatments are better. They are not as as they used to be and that in itself, I think, helps improve the quality of patients’ lives. But also I think that the publicity given to the psychological stress and trauma caused by the disease has actually made people recognize the need to have professional counselers available in clinics. It’s very rare, certainly in the UK now, to have a specialist breast unit where you don’t have automatically to it a specialist breast care nurse who may also be skilled in counselling. And for those women found to be experiencing high levels of there are people skilled in anxiety management, relaxation therapy and so forth to help them through the worst bits of their disease.

I think there’s another change as well that is important which is that it’s no longer a that people have to suffer in silence about. I think that we live in a more open society now where people can that they’re having problems and get help from others. And that might sometimes be friends. We previously used to have women actually hiding the fact that they’d even had the disease.

I think breast cancer is a pretty horrible disease and the best way of improving quality of life is to plug away still at clinical trials of different treatments. But it’s not all . There are support services available that sometimes bring enormous relief to many of the women enough to get the disease.

Living with breast cancer

Breast cancer is the major killer of women in the Western world. Despite enormous resources devoted to research on breast cancer, we have not yet made a significant impact on the life expectancy of patients diagnosed with the disease. In the last 10 years, however, attitudes to breast cancer have changed. The debate on screening continues. Patients are demanding more and better information about their disease. Treatments have become less toxic and, increasingly, are taking into account not only the duration of survival, but the quality of that survival.

- Most treatments for breast cancer cause serious side-effects and physical distress, as well as psychological distress. Increasingly, patients are participating in the choice of their treatment options.

- I think in most Western countries there’s been a shift over the last decade towards more conservative forms of surgery for breast cancer; lumpectomy, wide local excisions and so forth.

This is due to a variety of things. Of course the pressures put upon doctors by many vociferous women’s groups, but also, data that’s started emerging from some important studies over the last ten years have shown that there is no difference in terms of survival between more radical surgery and conservative surgery backed up with radiotherapy.

The problem though with local excision, conservative forms of surgery, is that recurrence is still quite high, local recurrence in this group is still quite high. About 20 percent of women treated by lumpectomy probably end up having a mastectomy and for some women that’s quite unacceptable. And so when given a choice, if they’re truly informed of all the various risks involved with the different procedures, quite a few will still actually prefer to opt for mastectomy rather than lumpectomy. Another good reason for women sometimes preferring - although it seems rather odd, some women genuinely prefer to have a mastectomy - is to avoid radiotherapy.

Certainly it’s common in most Western countries now to always accompany lumpectomy with radiotherapy, and for some women this can be one of the most unpleasant aspects of treatment. Some people are very unhappy about the texture, the sensations of the conserved breast following radiotherapy and many women are very bothered by the enervating fatigue that one can experience following a course of radiotherapy.

- The availability of less toxic chemotherapy, effective hormone therapy and more potent antiemetics are making adjuvant treatment more acceptable.

- Chemotherapy always sets fear in the hearts of people the moment any doctor tries to mention it to them. But I think that again most studies that have been done over the last ten years in particular, the overview studies, have shown how important adjuvant chemotherapy is, particularly in the under 50s. There is an advantage to about 15 percent, to women under 50 who have adjuvant cytotoxic chemotherapy. And the role of tamoxifen in the post-menopausal woman, hormonal adjuvant therapy is of course extremely important in preventing breast cancer in the contralateral breast and in the treated breast if it’s been conserved.

Although I think women are still extremely fearful of chemotherapy, actually some of the regimens for breast cancer are not as toxic as many of the regimens that are given for other forms of cancer. That’s not to say these side-effects should be dismissed. For some women it is intolerable and they will fail to complete a course of treatment. But for others it’s usually not quite as bad as expected and of course with the advent of the new antiemetics we can at least prevent, to a certain extent, or at least ameliorate one of the worst aspects of chemotherapy which of course was nausea and vomiting.

- In theory, early detection should make it possible to treat earlier and achieve better results. Which populations should be screened? When and how should they be screened?

- Well this issue of who, when, how - as far as screening is concerned ¬- is a very thorny one and causes a great deal of argument at every academic meeting you ever go to. If we can take the case of breast self- examination to start with, there’s actually little clear evidence that women who examine regularly necessarily experience a reduction in the severity of their disease. One of the problems is that even those women who do examine themselves regularly, seem to delay in reporting symptoms they find for just as long as those women who never examine or very rarely and just accidentally find a lump.

Reasons women give for not doing it? Some are very uncertain about how to do it. Some just don’t like the idea of examining themselves. So you’ve got a lot of resistance to people doing it regularly and as I say little evidence to show that it makes a great deal of difference.

I mean the interesting thing here is how do you motivate people sufficiently to check their breasts, to go along and report symptoms and problems without inducing this crippling anxiety that makes them so fearful that they don’t do anything? I think that’s the key area that those of us interested in the psychological aspects of this disease are working on at the moment.

- Mammographic screening has also run into problems.

- As far as mammographic screening is concerned, well again there is a lot controversy about how often this should be done and which age groups it should be done for. In the UK, various bodies were set up to initiate a national breast-screening program and it was decided after reviewing all the evidence available from various studies conducted in the US and Sweden and so forth, that the optimal age group for mammographic screening should be women above the age of 50 and under the age of 65, because it was that group that seemed to achieve most benefit in terms of early detection of the disease. It’s hoped that, provided that group is screened once every three years, that we could reduce the mortality from breast cancer by 25 percent.

However there’s a catch there because it assumes that 70 percent of women eligible who are invited to come along for screening will accept and do that regularly. It’s very difficult sometimes to convince people that they should go along for regular examinations unless they have symptoms. The idea of prevention, prophylactic care, is still alien to many people. And if you have to give up things like money, organize time off work or people to look after other dependents for you, and you’re not even ill, it’s difficult in fact to coerse, particularly some of the lower socioeconomic and educational groups to come along.

- Attitudes to breast cancer are changing at many levels. How have these changes affected the way oncologists treat patients?

- I think one of the big changes that’s occurred as far as oncologists are concerned is a recognition that they have to actually give patients a great deal more information about what’s going on. And I think it’s crucial of course that women do have information because it’s very hard for a woman these days to pick up a magazine or listen to a radio program that doesn’t contain something about breast cancer. So they’re aware that there are hundreds of treatments potentially available. So the doctor has got to offer some explanation as to why in their particular case he or she is recommending one treatment rather than another.

I think the other big change for oncologists is that they have got less toxic treatments to offer patients. Many of the chemotherapy regimens from ten years ago were pretty horrible things to go through and at least they know now as well with the 5-HT 3 antagonists that they have got effective means of helping with the emesis that’s associated very often with chemo.

- Patients’ attitudes are also changing and increasingly they are exerting their rights as consumers of health care.

- I think that one of the things that has changed is that women also are much more aware that they are a powerful lobby to improve things. I mean many of the changes that have come about have come about because of women making their voice heard, that they wanted more attention paid to some of the other areas of care that were being ignored, like the psychological aspects. In fact, I think sometimes now to the detriment of other patients with cancer, because many of the other patients that an oncologist will see don’t have quite the same level of public sympathy and support, let alone official channels of support that women with breast cancer have.

I think that part of anxiety reduction is access to adequate information, and certainly information has improved. It’s easier to access information, to get explanations about what’s going on. I think women, those who belong to the higher socioeconomic groups, certainly know that they can shop around and actually they don’t have to accept the first treatment that is offered to them by somebody.

- Communication skills in dealing with patients are now recognized as a critical factor in helping patients to adjust.

- We’d got lots of evidence from studies we’ve done over the past ten years, in particular with women with breast cancer, showing that one of the most important parameters influencing effective long-term adjustment to the disease and treatment was the communication skills of the original doctor who broke the bad news about the diagnosis and discussed the various treatment options available.

The Royal College of General Practitioners for example, certainly have made greater efforts to improve the communication skills training of GPs and a lot more is being thrown on their shoulders. I think increasingly with the health care reforms in the UK over the last few years, a lot of the follow-up, routine follow-up of patients with cancer that might have previously taken place in the hospital will be devolved to general practitioners. So they’ve got to hone not only their own skills in terms of communication but also their own education about cancer and what information to give people.

The situation today

- Sadly, I think that for most women the diagnosis of breast cancer, well even actually the discovery of a breast lump comes as a horrible shock to them. It still does conjure up a great deal of fear and anxiety. And rightly so, I mean it’s still the biggest killer of Western women. One only has to look at the statistics to recognize that those fears are not totally unfounded. I think it’s a rather sad thing to admit that, despite the billions of pounds and dollars that have been spent on research, we’re not really doing very much to prevent the disease and the deaths from it. I mean I think people might be living slightly longer, but that could in fact be an artifact that we pick up the disease earlier and therefore it might appear that they survive longer.

But the quality of that survival is actually the important issue here from the point of view of somebody like myself who works on the support issues that are important in breast cancer. And I think that we do have evidence that women perhaps are living better with their disease. I mean first of all the treatments are better. They are not as noxious as they used to be and that in itself, I think, helps improve the quality of patients’ lives. But also I think that the publicity given to the appalling psychological stress and trauma caused by the disease has actually made people recognize the need to have professional counselers available in clinics. It’s very rare, certainly in the UK now, to have a specialist breast unit where you don’t have automatically attached to it a specialist breast care nurse who may also be skilled in counselling. And for those women found to be experiencing high levels of anxiety there are people skilled in anxiety management, relaxation therapy and so forth to help them through the worst bits of their disease.

I think there’s another change as well that is important which is that it’s no longer a topic that people have to suffer in silence about. I think that we live in a more open society now where people can admit that they’re having problems and get help from others. And that might sometimes be friends. We previously used to have women actually hiding the fact that they’d even had the disease.

I think breast cancer is a pretty horrible disease and the best way of improving quality of life is to plug away still at clinical trials of different treatments. But it’s not all gloomy. There are support services available that sometimes bring enormous relief to many of the women unfortunate enough to get the disease.