Patient Education Before Breast Cancer Surgery

As more breast cancer operations are performed on an outpatient basis, patient education before surgery has become even more important. In some hospitals, preparing women for what to expect during and after the surgery, teaching them how to care for themselves, and discussing emotional issues and coping skills is the work of nurse practitioners.

Kyle Terrell is a surgical oncology nurse practitioner at the Johns Hopkins Breast Center. She spends considerable time with breast cancer patients before they undergo mastectomy (removal of the breast) or lumpectomy (removal of the tumor and some surrounding tissue) with dissection of the lymph nodes. In addition to discussing the surgery, care after surgery, and other issues with the patient, she performs the preoperative physical examination and orders any preoperative tests that are deemed necessary. This time spent a day or two ahead of the patient's actual surgery day is called "the dress rehearsal." Every effort is made to educate the patient and her family fully about what to expect on the day of surgery as well as assess the patient's and family member's coping skills. By anticipating the patient's needs and educating her thoroughly about what to expect, the patient's anxiety is dramatically reduced and she remains in control of the situation lying before her. The surgical day is to be a "positive day" for the patient, as the surgeon proceeds to transform the patient from a victim into a survivor, ridding her body of the source of the disease. Based on patient satisfaction survey results, the more patient education provided to the patient, the more satisfied she is with her surgical treatment and overall care.

One of her most important responsibilities is teaching women how to care for surgical drains that are placed during the operation. Says Terrell: "The vast majority of these procedures are outpatient, and the patients will be going home with anywhere from one to four drains. So I go over the purpose of the drains and how to take care of them."

When breast cancer surgery is performed, a space is created in the body where there used to be tissue. The body's natural response is to fill this space with fluid. Similarly, when lymph nodes are removed, it may take the body some time to reroute the lymph fluid. The drains placed during surgery remove excess fluid. When the amount of drainage decreases to a point where the body can easily absorb the fluid, the drains are removed. Until then, breast cancer patients must measure the fluid that is drained and keep the surgical incisions clean and protected. The drains are typically removed within one to three weeks following surgery.

In addition to drain care, Terrell spends some time discussing pain management and the stresses of surgery, both physical and emotional. To deal with fatigue, she encourages patients to get up and move around as soon as possible after surgery. Hopkins patients also meet with an occupational therapist before surgery, who teaches them arm exercises to perform after surgery.

While a patient is recovering shortly after surgery (in the recovery room for outpatient surgery patients, and one day post-operatively for inpatients undergoing mastectomy with reconstruction), Terrell visits her again. During this visit, she gives the patient or the patient's caretaker some hands-on experience caring for the surgical drains. She also checks on how the patient is feeling, for example whether she is experiencing any pain or nausea. The nurse practitioner is also in touch with the patient daily while the drains remain in place.

The next time she sees the patient is typically one to three weeks after surgery, when the surgical drains can be removed. "I think most people are surprised by how well they actually do after surgery," says Terrell. The majority of breast cancer patients (95%) at Hopkins having mastectomy without reconstruction or lumpectomy with axillary node dissection are discharged from the recovery room and choose to go home rather than spend the night in the hospital. They usually have effective pain management control with the use of just oral pain relievers upon departure from the hospital setting. It is the faculty's theory that by having the patient achieve a positive surgical experience sets the stage for good experiences with the rest of her breast cancer treatment.

"My job is to help [breast cancer patients] through the diagnosis and surgery, prepare them for what will happen next and get them on their way," says Terrell. "Sometimes they'll call me much later and let me know how they're doing. It's very gratifying to see how they grow and get through the challenges."