Breast Cancer-A Developing Paradigm of Nursing Care in Israel

The medical care has changed in many respects [1,2]: A less aggressive surgery, offering women lumpectomy (breast conservation) rather the traditional mastectomy (total breast removal). The change in surgery means also not removing all the lymph nodes (The traditional Axillary Lymph Node Dissection) and having, in many cases, just a sentinel lymph node biopsy. Another change that occurred in the last decade is regarding breast reconstruction techniques. A much less aggressive chemotherapy and many more treatment to treat the side effects of chemotherapy exist. New biological agents, more oral chemotherapy options, advances in hormonal treatments and many advances in radiotherapy options with a shorter treatment time and the new established use of intraoperative radiotherapy.


Background
In the last two to three decades a lot has happened in the care for women diagnosed with breast cancer that effected the development of breast care nursing.
The medical care has changed in many respects [1,2]: A less aggressive surgery, offering women lumpectomy (breast conservation) rather the traditional mastectomy (total breast removal). The change in surgery means also not removing all the lymph nodes (The traditional Axillary Lymph Node Dissection) and having, in many cases, just a sentinel lymph node biopsy. Another change that occurred in the last decade is regarding breast reconstruction techniques. A much less aggressive chemotherapy and many more treatment to treat the side effects of chemotherapy exist. New biological agents, more oral chemotherapy options, advances in hormonal treatments and many advances in radiotherapy options with a shorter treatment time and the new established use of intraoperative radiotherapy.
It can therefore be said, that oncology as a whole, and breast cancer specifically, in one of the clinical areas that experienced a dramatic, rapid and exiting expansion. This makes the breast care nurses to be all the time updated. This is especially related to patient education, symptom assessment and treatment.
Beyond these changes in the medical care, many advances happened also in the understanding of all the psychosocial effects of the disease on the woman and her dear ones. These advances are all related to the relatively new science, which is defined as psycho-oncology. Psychooncology started developing mainly in breast cancer care and nowadays is applied to all areas of oncology [3]. Nurses are part of the psychoncology team but differs from the role of the social worker and the psychologists by the holistic nature of their work and education which sees the person as a whole from its somatic, social and emotional nature as a whole. Topic researched at the early stages of psychooncology were coping with diagnosis with cancer, as well as understanding the issue of palliative care and the development of the hospice movement. Psycho-oncology is increasing its knowledge both globally (not only in the western world) and in Israel as well. Topics such as long term living with the disease (survivorship) and the fear of recurrence are just an example [4].
Because nurses are the most available and follow the patient 24 hours a day, along all stages of the disease they also must have a wide education in psycho-oncology. However and beyond that, they must know the boundaries of their profession and therefore they must work within a multidisciplinary team, such as psychologists, social workers, radiologists, pathologists, surgeons, medical oncologists and radiation oncologists [5,6].
The issue of Breast Care nursing has developed in the UK and in other parts of Europe in the late nineteen eighties as a Clinical Nurse Specialist which emphasized mainly on psychological counselling and advice [7,8]. In North America the job was seen under the role of the Advanced Practice Nurse putting more emphasis on the medical care and the role of a nurse navigator [9][10][11]. In Israel, however, we combined both the European and the North American models of care to describe the role as the Breast Care Nurse Coordinator [12]. The emphasis here is as it's said -coordination of the care for the woman and her family. This means following the woman and helping her with managing the complex medical system in all the aspects which are needed -from the emotional, educational to practical aspects of helping her with making appointment to the various settings -both in the hospital and in the community.

The Situation of the Role in Israel
In Israel, Breast Care Nursing (BCN) is a very heterogenic role. Some BCNs work in the hospitals following the women along all the process of the medical care. Other BCNs are related more to the surgical or the oncology part of care. In the last years there are more specific roles for the BCNs, such as advising in the genetic clinic or the radiology clinic. The most recent role for BCNs in Israel is now being applied in the community (and mostly funded by the Israel Cancer Association). It is very important that all the BCNs, both in the hospital and the community communicate within each other.
Some of the different new roles of the BCNs are defined below as described by themselves:

BCN in the radiology department
These nurses help with the procedures involved, give telephone advice, coordinating care with others in the multi-disciplinary team, organizing a pleasant and welcoming environment, doing some research with other breast care nurses and others in the multidisciplinary team.

BCNs in the community
These specialist Breast Care Nurses work in various parts of the country within the community. Their role is an important connection between the hospital and the community. They follow the woman and her family in the care at home in visits between treatments. They also give help in symptom managements of all the treatments, with an emphasis according to their nursing diagnosis. They are also helping patients in making appointments for the tests needed in the hospital and out with. The most important is coordination of care between the community doctor and the woman.