Patient Counselling in Breast Cancer: A Comprehensive Review of Strategies and Clinical Outcomes

Abstract

Breast cancer is the most prevalent and second largest cause of cancer-related death among women. Long-term survival rates have increased since 1990. Every year, approximately 200,000 new cases of breast cancer are identified, and more than 40,000 individuals die as a result of breast cancer. In the United States, there are currently over 2.5 million breast cancer survivors. However, the majority of breast cancer patients are surviving longer. The long-term impacts and quality of life issues that breast cancer survivors confront, such as mental disorders including anxiety and depression, sexual dysfunction, and lifestyle changes, are becoming more apparent and worrying. Fortunately, Patient Counselling services have become considerably more available to patients who have survived breast cancer in recent years. Breast cancer demonstrates how it impacts a woman's physical, emotional, and social status. However, crucial variables such as family and social support can assist to alleviate the symptoms of sadness and anxiety. The actual cause of breast cancer is unknown, however risk factors for the disease have been identified. Breast cancer risk factors include aging, a family history of the disease, specific changes to the breast, gene changes, menopause and reproductive history, sedentary lifestyle, alcohol use, obesity, nutrition, race and chest radiation therapy.

Keywords

Breast Cancer, Patient Counselling, Quality of Life, Breast Cancer Survivors, Anxiety and Depression.

Introduction

Breast cancer is a most common disease worldwide which requires effective and rational therapy. In recent years, the incidence of cancer has risen significantly, affecting not only physical health but also mental and social well-being. This multifaceted impact has made cancer one of the major challenges of our time ^[1]. In many Indian societies, it is common for individuals to marry early, experience early and multiple childbirths, and engage in extended periods of breastfeeding for all their children.  However, the more educated class is moving away from this pattern, with later-age childbirth and minimal or no breastfeeding due to shift is attributed to evolving social values and the professional demands of jobs on working women. The rising incidence of breast cancer may, be responsible to these evolving practices and societal shifts ^[2]. The majority of breast cancer cases in India are identified by patients themselves, often at a stage characterized by a palpable lump or secondary changes like local skin or chest wall alterations, or even distant metastases ^[3]. Nearly half of Indian patients show indications of skin invasion, such as oedema, ulceration, and fungation, or chest wall manifestations ^[4].

1. Epidemiology

Epidemiological research indicates that the worldwide incidence of breast cancer is cross nearly 2 million cases by the year 2030^[5]. India exhibits a comparatively lower 5-year survival rate for breast cancer when compared with Western and other high-income countries ^[6]. The incidence of cancer in India experienced a significant increase of nearly 50% between 1965 and 1985 ^[7]. In 2016, the estimated number of incident cases in India was 118,000 (with a 95% uncertainty interval of 107,000 to 130,000), of which 98.1% were females. The prevalent cases were 526,000 (with a range of 474,000 to 574,000). In the past 26 years, the age-standardized incidence rate of breast cancer in females has raised by 39.1% (with a 95% uncertainty interval of 5.1 to 85.5) from 1990 to 2016, and this increase has been observed in every state of the country ^[8]. GLOBOCAN predicted a 57.5% increase in cancer cases in India by 2040, reaching 2.08 million, when compared to the 2020 ^[9]. Survival rates for breast cancer patients in India are lower than in Western countries due to factors such as an earlier age of onset, late-stage diagnosis, delayed initiation of treatment, and inadequate or fragmented care ^[10].The World Cancer Report 2020 emphasizes that the most effective approach for breast cancer control is early detection and with prompt   treatment ^[11]. A 2018 systematic review of 20 studies revealed that treatment costs for breast cancer escalated with advanced stages at diagnosis. Hence, an earlier detection of breast cancer has the potential to reduce overall treatment expenses ^[12]. The World Health Organization (WHO) defines quality of life as an individual’s perception of their position in life relative to their expectations, standards, and concerns. Cancer can significantly impact a patient's quality of life in numerous ways. The problems that affecting the quality of life of a patient are the mental and emotional impacts of illness, diagnostic and therapeutic measures, stress, pain, depression, and disease consequences Cancer can affect a patient's quality of life through its impact on family, marital, and social relationships, as well as by creating economic burdens, nutritional challenges, and treatment complications. Enhancing the quality of life for cancer patients is a primary goal of medical and therapeutic care ^[13-15].

2. Signs and Symptoms

Breast cancer can cause nipple abnormalities, discharge from nipple, inverted nipple, change in colour of nipple, change in shape/size of breast, breast swelling, breast pain, skin abnormalities, back pain, abdominal pain, chest pain, fatigue, weight loss, appetite loss, nausea, and vomiting ^[16].

3. Risk factors       
   1. Non-modifiable risk factors include:

• Genetic factors (Major inheritance susceptibility of pathogenic variant of BRCA1 and BRCA2 genes and other breast cancer susceptibility genes ^[16-20]
• Breast tissue density (mammographic) ^[21]
• Menstrual history (early menarche/late menopause) ^[23]
• Nulliparity
• Older age at first birth
• Female sex
• Family health history of breast/ovarian cancer
• Previous radiation therapy, not having pregnancy and breast feeding ^[23-25]
  2. Modifiable risk factors include:

• Sedentary lifestyle ^[26]
• Obesity
• Poor diet,
• Use of oral contraceptive pills
• Hormonal replacement therapy
• Alcohol intake
• Smoking
• Intake of processed food like red meat, dairy products like saturated fat, calcium ^[23-25]

4. Guidelines for the early detection of breast cancer

For patients aged 20 to 30 years, schedule a clinical breast exam with a healthcare provider at least once every three years and perform a monthly self-exam of the breasts ^[27]. If the patient Age between 40 and Greater than 40years, Schedule an annual mammogram, arrange for a yearly clinical breast exam by a healthcare provider and perform a monthly breast self-exam ^[28-32].

5. Aim of counselling  

The primary objective of counselling is to empower patients, instilling them with the confidence to make choices and decisions. Empowering patients and their families is the most effective way to enhance their health ^[33]. Patient empowerment is the process through which individuals enhance and strengthens their necessary resources, gaining the ability to take control of their lives, address their needs, and solve their problems. Empowerment also leads to access to appropriate and quality care, enhanced quality of life, increased responsiveness, better interactions with medical staff, greater satisfaction, improved response to therapy, avoiding complications and a positive attitude towards the disease ^[34]. A study on empowerment factors revealed that using a family-centered empowerment model significantly enhanced the functional aspects of life quality for breast cancer patients undergoing chemotherapy ^[35]. Educating women on the importance of nutritional adjustments, regular physical activity, and the cessation of alcohol consumption and smoking can help reduce the risk of breast cancer ^[36]. It involves guiding individuals to explore various strategies for coping with their diagnosis, addressing emotional Top of Form concerns and discussing ways to manage lifestyle changes during the treatment process managing their emotional concerns and discuss ways to address and cope with any lifestyle changes that might occur during the treatment process ^[35-36]. 

1. 1. Lifestyle changes  

Managing weight gain, fatigue, and diet after treatment poses common lifestyle-related challenges for many breast cancer patients ^[31,37]. These issues are frequently inter-related ^[38]. During cancer treatment, there’s a tendency for positive health behaviors like exercise to decline, while negative ones such as consuming nutritionally poor foods often increase it. In light of growing epidemiological evidence that weight gain is implicated in risk for breast cancer recurrence as well as decreased survival, numerous interventions have been developed for women to help change their diet and lose weight ^[39]. In addition, studies that have focused on physical activity as the main predictor of weight loss have demonstrated the multiple quality of life benefits that additionally come from exercise beyond the reduction of body weight. For instance, Regular exercise has been demonstrated to positively affect anxiety, depression, overall mood, and self-image ^[40]. To examine the impact of variations in lifestyle factors both individually and collectively, we identified five modifiable lifestyle-related factors linked to breast cancer development. Each factor was categorized as favorable or unfavorable according to international standards set by the WCRF/AICR and the World Health Organization ^[41].

Body composition favorable—BMI < 25 kg/m2 versus unfavorable—BMI ≥ 25 kg/m2.

Physical activity favorable—moderate or more physical activity versus unfavorable—sedentary physical activity.

Alcohol use favorable—no alcohol or ≤ 1 day a month drinking alcohol versus unfavorable— > 1 day a month drinking alcohol.

Smoking favorable—no current smoking versus unfavorable—current smoker.

Hypertension favorable—systolic blood pressure < 140 mmHg, diastolic blood pressure < 90 mmHg, and no antihypertensive medication versus unfavorable—systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg, and/or use of antihypertensive medication

1. 1. 1. Physical activity 

Research have shown that physical activity can improve physical, psychological/emotional and social functioning help reduce treatment related side-effects such as pain, fatigue, nausea etc. Exercise is increasingly implemented as a therapeutic tool in patients with breast cancer which is effective in improving quality of life and survival ^[42]. Along with weight loss, a number of research studies have found that physical exercise can improve fatigue and decrease inflammatory markers in breast cancer patients. Exercise regimens may be self-directed, home-based, or group-based. physical activity reduces risk of all-cause mortality and breast cancer specific mortality for survivors ^[43]. Regular exercise and physical activity in postmenopausal women reduce the risk of BC by altering estrogen, insulin and insulin like growth factor 1[IGF-1]levels  ^[44].

1. 1. 2. Diet

Research has shown that nutritional counselling and education has proved to be greatly beneficial in improving the eating habits of breast cancer patients and have found that the most frequent dietary changes among breast cancer survivors include reducing dietary fat intake and increasing the consumption of fruits and vegetables.

Plant based diet: Mainly contains fruits, vegetables, grains, legumes, nuts and seeds  

Mediterranean diet: Contains fruits, vegetables olive oil, beans, dairy, and proteins. It may reduce risk of breast cancer and positive effect on mortality rate ^[42,43].

Dietary Guidelines to manage treatment side-effects  

Anorexia/ Loss of Appetite: Manage anorexia through medications like corticosteriods and progesterone analogs, and diet includes: To manage anorexia is essential to eat foods that are a good source of protein which include: Lentils and beans, Yogurt, Eggs, Lean meat, protein-dense foods first in meal when appetite is good, Sip minimal amounts of fluids during meals Include milkshakes, smoothies, juices, or soups, Eat foods with good aroma and flavor ^[45].

Nausea: Eat foods that are bland, soft, and easy-to-digest, dry foods like crackers, bread sticks, or toast, have foods that are light on the stomach like bread toast, plain yogurt, and clear soup or broth, avoid heavy and strong aromas in food and drink, Rinse your mouth before and after eating, Sit up or lie down with head elevated for at least an hour after eating.

Vomiting: Vomiting is one of the common side-effects of breast cancer treatment due to the drugs and chemotherapy, to manage it follows some tips include: Do not eat or drink anything until the vomiting’s stop, drink small amounts of clear fluids once the vomiting settled, have 5 or 6 small meals every day instead of 3 large ones ^[46,47].

Constipation: To manage constipation patients should include: Plenty of fiber-rich foods and increased fluid intake, engage in low-intensity walking, have warm beverages to regularize bowel movements. After eating, either sit up or lie down with your head raised for at least an hour ^[48,49].

Fatigue: To overcome fatigue and stay active throughout the day: Choose high-protein snacks, have small frequent meals rather than large meals, drink plenty of fluids and have energy-dense foods to maintain fuel reserves. Exercise may beneficial in managing cancer related fatigue ^[50]. Regular physical exercise enhances functional capacity, making daily activities easier to perform with less effort and also enhances the health of patients who have undergone multiple rounds of chemotherapy and radiation therapy for breast cancer ^[51].

Weight Gain: The use of corticosteroids prescribed to ease nausea, and swelling, to chemotherapy are the reasons for weight gain. To prevent weight gain, follow these dietary modifications: Eat foods that are loaded with dietary fibre like whole-grain cereals, millet, brown bread, have low-fat milk products, Limit salt intake, Get involved in a mild form of exercise daily ^[52].

Alopecia: The incidence of chemotherapy-induced alopecia (CIA) in cancer patients continues to increase. Between 40% and 100% of breast cancer patients experience complete hair loss during chemotherapy, while the rest endure thinning or weakened hair. Patients with 8% have declined chemotherapy due to the intense anxiety associated with CIA ^[53]. In patients with early-stage breast cancer, the DigniCap system (a scalp cooling device) demonstrates effectiveness as a supportive care tool ^[54].

1. 1. 3. Alcohol  

Alcohol consumption is the lifestyle factor mostly associated with increased risk of BC. Women with high level of alcohol consumption have 40-50per higher risk of developing breast cancer ^[55]. Drinking even small amounts of alcohol is linked with an increased risk of breast cancer in women ^[56]. Alcohol can raise estrogen levels in the body through several mechanisms, which may explain some of the increased risk ^[57]. Avoiding or cutting back on alcohol may be an important way for many women to lower their adverse effects on health and risk of breast cancer ^[58].

5.1.4 Smoking  

Smoking cigarettes significantly increases the risk of negative outcomes in cancer treatment. Both those who actively smoke and those who are exposed to second hand smoke face an increase risk of developing breast cancer ^[59]. Continuing to smoke after a cancer  diagnosis can increase the risk of all-cause mortality, cancer recurrence, and side effects during cancer treatment ^[60]. Quitting smoking as early as possible can reduce these risks and can increase survival ^[61]. Female smokers who have undergone a partial mastectomy for breast cancer face approximately 6.7 times the risk of complications compared to women who have never smoked ^[62].

1. 2. Social support

Research shows that social support plays a crucial role in helping cancer patients manage the stress of their illness ^[63]. social connections have been demonstrated to be valuable resources for patients in coping with cancer. This type of support can reduce the negative impacts on health and provides cancer patients with care and attention, and helps them to overcome their fear and anxiety from the disease and ease the difficulties they experience at different stages of their illness ^[64].

1. 3. Psychological support

Women with a primary breast cancer diagnosis are susceptible to psychological disorders for many years. Among various psychological approaches, cognitive behavioural therapy (CBT) is particularly effective in enchancing emotional well-being and helping patients cope with the disease ^[65]. Psychoeducation has become a widely used adjunctive psychosocial intervention for cancer patients and their families. Psycho education is a promising intervention to help patients throughout the breast cancer care pathway. It may help them cope with various challenges throughout the BC care time frame, reduce symptoms of anxiety and depression and improves the quality of life ^[66].

6. Protective Factors

The following protective factors and interventions reduce the risk of female breast cancer:

• Estrogen use (after hysterectomy) ^[67]
• Exercise
• Early pregnancy
• Breastfeeding
• Selective estrogen receptor modulators (SERMs)
• Aromatase inhibitors or inactivators ^[68]
• Risk-reducing mastectomy
• Risk-reducing oophorectomy or ovarian ablation ^[69]

7.  Do’s for a Cancer Patients

• Listen to your body and respect its signals: If you're feeling tired, it's okay to say 'no' to activities, even if you want to participate. Pay attention to what your body is telling you."
• Allow yourself to cry if you need to: Many cancer patients have found that expressing their emotions through crying can bring a sense of relief and improve how they feel.
• Embrace change: Evaluate what you need to let go of and work on accepting it. This will help you create space for a new way of life and adapt to the changes.
• Address your medical concerns: Make sure to resolve any questions or doubts about your cancer treatment with your medical team. They are the best resource for understanding your condition.
• Maintain a diary: Record all your questions and concerns in a personal diary. Bring it along to your next hospital visit to discuss them with your medical team.

8. Don’ts for cancer patients 

• Share your worries and feelings with those closest to you. It’s important to discuss them at the right time for support and understanding.
• Don’t hesitate to discuss your emotional well-being and seek counseling if you feel it’s necessary.
• Don’t suffer in silence. Take advantage of the many resources available today, including numerous online initiatives that offer emotional support for patients.
• Don’t feel guilty if you can’t stay positive all the time. While others may encourage you to remain upbeat during tough times, it’s perfectly normal to have moments when maintaining positivity is challenging.
• Don’t blame yourself for your cancer diagnosis. You are not at fault for your illness. Even if you’ve engaged in risky behaviors like smoking or alcohol use, it doesn’t mean you are to blame for your diagnosis.
• Don’t think that a cancer diagnosis means an early death. With advancements in treatment, there are now many effective options available, and the number of cancer survivors is steadily increasing.
• Don’t waste your energy on how others perceive your medical condition. With many myths and misconceptions about cancer in society, their opinions are not important right now. Focus on your own journey and well-being.
• Don’t forget to express your gratitude to your caregivers. Showing appreciation, even through small gestures, can have a significant impact and is an important way to acknowledge their support.
• Don’t concentrate solely on cancer. Instead, focus on your overall well-being and keep engaging in activities that bring you happiness ^[70-72].

9. Supportive care during treatment

Patients undergoing breast cancer treatment necessitate supportive care to prevent and address the physical and psychosocial side effects associated with cancer therapies. Supportive care encompasses services designed to assist cancer patients, their caregivers, and families in managing the disease and its treatment throughout the patient's journey. These services aim to maximize treatment benefits and help patients cope effectively with the impact of the illness ^{[73] .} Supportive care focuses on enhancing and maintaining the patient's quality of life by addressing various needs, including physical and symptom management, education, social and psychological support, spiritual care, and rehabilitation ^[72]. It also encompasses end-of-life and bereavement care, requiring coordinated efforts and collaboration across multiple disciplines ^[74]. Supportive care needs vary among breast cancer patients and depend on factors such as the stage of the disease (early, advanced, or metastatic breast cancer), the patient’s age (e.g., young women of childbearing age or older women), their social and cultural context, and individual perceptions. Supportive care tends to receive less emphasis in low- and middle-income countries (LMICs). Incorporating supportive care strategies into established breast cancer treatment programs is crucial for a comprehensive approach to cancer care, involving multidisciplinary collaboration. Supportive care during and after cancer treatment is crucial and should be accessible, affordable, and available to all patients and their families ^[75]. Unfortunately, these needs are often unmet, particularly in systems with limited resources, where supportive care is frequently given low priority ^[76]. Neglecting supportive care in cancer treatment can reduce patients compliance and worsen outcomes, thereby diminishing the value of therapeutic interventions ^[77].

CONCLUSION 

To summarize, substantial progress has been made not only in enhancing breast cancer survival, but also in generating effective patient education and intervention that is directly associated to improved quality of life. In cases of breast cancer, effective patient counseling is an essential part of all-encompassing care. It empowers patients by giving them accurate information about their prognosis, possible side effects, treatment alternatives, and diagnosis. Counseling helps people deal with emotional, psychological, and social issues by using compassionate communication to help them manage their worry, fear, and uncertainty. Patients are actively involved in their treatment programs since it also promotes joint decision-making. All things considered, patient counseling promotes better clinical outcomes in the treatment of breast cancer, increases adherence to therapy, and improves quality of life. For many patients, the challenge is finding the appropriate venue or opportunity to access such resources. The clinical encounter that takes place between a patient and her primary care physician or gynecologists in many ways offers an ideal opportunity to begin addressing needs for psychosocial patient education and intervention after breast cancer.

CONSENT : It is not applicable

ETHICAL APPROVAL : It is not applicable

DISCLAMIER (Artificial intelligence)

Author hereby declares that NO generative AI technologies such as Large Language Models (ChatGPT, COPILOT, etc) and text-to-image generators have been used during the writing or editing manuscripts.

Relevant conflicts of interest/ financial disclosures: The author declare that the research was conducted in the absence of any commercial or financial relationships that could be constructed as potential conflict of interest.

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