TURKISH JOURNAL OF ONCOLOGY

Summary

In both Turkey and the world, breast cancer among women is the most diagnosed type of cancer. Breast care nursing in the world has evolved over the last 30 years in Australia, Canada, Europe, England, Ireland, the USA, Scandinavia and Benelux. International guidelines have required a breast care nurse to be involved in the multidisciplinary team to support patients with breast cancer. The European Expert Breast Cancer Association has stated that there is a need for at least two breast care nurses in a breast care center in the standards for the Specialist Breast Care Unit Requirements that were revised in 2013. In the UK, the Royal Nursing College was revised in 2017 in line with the guidelines of clinical practice standards. In Turkey, although the concept of breast care nursing is not settled, the opportunity for the nurses to specialize in the field of breast cancer care should be offered. Breast Care Nursing courses are organized by the Oncology Nurses Association. It is envisaged that this program to be approved by the Ministry of Health by providing the certification standards and that the dissemination in the state, university and private hospitals throughout the country will contribute to cancer care as cost-effective care.

Summary

Introduction

Cancer in the world and in Turkey ranks second among causes of death. Cancer, global approximately one out of every six deaths in Turkey is also one of the main causes of every five deaths.[1] In the future, an increase in the world population, the aging of the population and the increase in cancer risk factors are expected to increase the cancer burden.[2] According to the latest data of the International Agency for Research on Cancer (IARC); the global cancer burden in 2018 increased to 18.1 million new cases and 9.6 million cancer death rates.[3] According to cancer statistics in 2015 in Turkey, approximately 170 thousand new cases of cancer (97 830 men and 69 633 women) are estimated to be detected.[2]

Breast cancer comes in first place among women diagnosed with cancer in the world and Turkey. Globally, the rate of breast cancer has been reported as 11.6% (2089 million).[3] According to Turkey"s Ministry of Health statistics for 2015, one in four women diagnosed with cancer has breast cancer, and a total of 17.183 women were diagnosed with breast cancer within one year.[2]

Breast cancer treatment, as presented in the results of many clinical studies from the diagnostic methods and new treatment options, is developing rapidly. In this context, health workers should be trained in evidence-based practices and about current and emerging scientific data to provide the best care for patients with breast cancer. [4] Supportive care should be provided to patients diagnosed with breast cancer by nurses who are specialized in this field at every stage of the disease process.

Breast care nurse is a nurse who is consulted for health requirements and preferences, to maintain the health and well-being of breast cancer patients concerning information, education, psychological and emotional support and care coordination by providing continuity and clinic care at all stages of care, including diagnosis, treatment, rehabilitation, palliative care and follow-up.[5]

Breast Care Nursing Competency Standards
Competency standards for breast care nurses in the guide published in 2005 by the Australian National Cancer Center was developed in five key areas,[5] which are detailed below.

1. Supportive care: To implement sustained and evidence- based supportive care initiatives to achieve the best health outcomes in the context of a multidisciplinary approach based on a collaborative, flexible and responsive approach to the physical, psychological, social, sexual and spiritual needs of patients with breast cancer.

2. Common care: Common care includes competencies reflecting the ability to assist care planning, implementation and evaluation cooperation.

3. Coordinated maintenance: Coordinated maintenance includes the ability to coordinate the health and support services needed in a comprehensive care planning, implementation and evaluation approach in a timely, flexible and efficient manner.

4. Providing information and training: In a comprehensive manner specific to patients about the pathophysiology of breast cancer and individualized information and their effects, treatment, supportive care and self-management strategies, such as individual clinic situation, are compatible with the evidence-based educational strategies, preferences, knowledge and provide personal care needs.

5. Clinic leadership: This area includes competencies that reflect clinic leadership and professional activity and cancer care ability to improve breast cancer care.[5]

Roles of Breast Care Nurse
In 2017, the European Society of Breast Cancer Specialists (EUSOMA) attached the importance of accessing to nurse counseling in breast cancer care. Accordingly:

The Rate of Patients Applying for Nurse Counseling During the First Treatment:
Breast care nurse; while providing cooperation with multidisciplinary team members, also fulfill their roles as a supportive, educator and advocate to improve the quality of life of breast cancer patients by providing supportive cancer care with evidencebased care practices. They take the caring role for the physical, psychological, social, sexual, cultural and spiritual needs of breast cancer patients (Evidence Level IV).[6]

Rate of Women Diagnosed with Breast Cancer With Direct Access to a Breast Care Nurse for Information and Support on Treatment-Related Symptoms and Toxicity During Initial Treatment, Follow-Up and Rehabilitation:
Nurse"s leadership in line with the information needs of the patients and providing greater access to psychosocial support and the continuity of care can yield better results (Evidence Level IV).[6]

EUSOMA has set training standards by publishing best practices and evidence-based guidelines to provide specialized training to the core team of different disciplines (i.e., surgeon, medical and radiation oncologist, pathologist, radiologist and breast care nurse) in breast care centers. The purpose of these training standards is:

? To establish the minimum theoretical and practical knowledge that should be certified as a healthcare professional in the field of breast cancer.

? To determine the evaluation strategy needed to assess the competence of specialist title in breast cancer. The standards for the content of training of breast care nursing are given in Table 1.[7]

Table 1: Breast care nursing theoretical training content standards[10]

Breast Care Nursing in the World
Breast care nursing has evolved over the last 30 years in Australia, Canada, Europe, England, Ireland, the USA, Scandinavia, and Benelux (Belgium, the Netherlands and Luxembourg).[8] In this process, breast care nursing, according to a very comprehensive range of roles as nurse training and experience, experienced clinical nurse specialist, nurse specialist, nurse specialist in breast care and breast cancer, are available.[9]

Breast care nursing first started in the early 1980s as a specialty in England. Breast care nurses, first described in England, are specialist cancer nurses who provide information, support and counseling to breast cancer patients from the new diagnosis process. Breast cancer nursing, first established in 1996, is carried out in accordance with the guidelines of the Royal Society of Nursing (RCN), which was published in 2007 and revised in 2017 under the clinical practice standards.[10]

In this guide, breast care nursing can be applied at four levels as follows:

1. Breast care nurse: Carries out breast care and support roles.

2. Expert breast care nurse: Carries out the role of developing, supporting, encouraging, evaluating, coordinating and maintaining care.

3. Expert clinic nurse: Carries out the roles of planning, implementing, evaluating, analyzing, forming strategies, developing and leading practices of nursing care standards.

4. Counselor nurse: The role of developing and implementing strategies and policies, being open to innovations, research and disseminating the results.[10]

Breast care nursing is officially defined in Australian health care in the 1990s to provide continuity of care and psychosocial support.[11] In Australia, as a member of the multidisciplinary team in the 1990s, specialized breast care nursing was developed to provide better care and psychosocial support to breast cancer patients, and in line with this purpose, competency standards were published.[12] It was proposed to include breast care nurses in the treatment team in the clinical practice guide published in 2001 (Evidence Level II].[5]

In 1998, the foundations of the EUSOMA and Europa Donna (European Breast Cancer Coalition) organizations were laid in Florence by the European Organization for Breast Cancer Treatment and Research. It is emphasized that there is a breast care center at every 250 thousand population and equipped with a multidisciplinary team, including experts from oncology and other disciplines and breast care nurses.[13] EUSOMA stated that there is a need for at least two breast care nurses in a breast care center in the standards for Specialist Breast Care Unit Requirements published in 2000 and revised in 2013.[14]

International guidelines have required a breast care nurse to be involved in the multidisciplinary team to support patients with breast cancer. In the UK, RCN has developed several modules for breast care nursing education. RCN has identified three levels as follows: breast care nurse in the career development of breast care nursing, clinical nurse specialists and nurse consultants. It proposed the preparation of structured training that includes specific characteristics of a higher level of breast care nursing, such as teaching, evaluation and counseling.[12]

Except for the experiences in the UK and Australia, it was determined that there is no common education curriculum in Europe, and there are national, cultural and political differences between nursing education and practice. While in some countries, nursing is a professional occupation with various specialties, it remains as an occupation that has not yet been recognized as a profession or has no formal education in some countries. It is reported that breast care nursing education and roles are different, and there is no standard education model because of these differences varying from country to country.[9]

Although there are breast care nurses in all health institutions, their education levels, defined and functional roles differ.[12] The European Oncology Nurses Society (EONS), to eliminate these differences and set the standard, contributed to the preparation of a joint guide in 2009 by preparing breast care nursing education curricula.[12] EONS has defined, as the aim of the breast care nursing education curriculum:

• To raise awareness of the need for trained nurses specialized in breast cancer care throughout Europe,
• To standardize the role of nurses working with patients with breast cancer and their families,
• To determine the standards for basic education and training of nurses in breast care.[8]

Since there is no common guideline at the European level, standards have been established based on the guidelines for breast care nursing in pioneering England, North America and Australia.[8]

Research on Breast Care Nursing
In Western Australia, Brown et al.[15] found that in a study conducted by the breast care nurse on the timing and method of consultation of the patients, the women who met face to face with the breast care nurse in the preoperative period had better education and emotional support than the women who had consulted with the breast care nurse during the phone call or postoperative period. If the general condition of the patient is appropriate, a consultation with the breast care nurse should be offered in the preoperative period. The best method to have a face-to-face consultation is to provide training and psychosocial support that patients need during the operation. In cases where this method cannot be applied, the patient should be given consultancy by telephone without waiting for the time of operation.

In a multicentre study on the perceptions of Israeli women with breast cancer regarding the role of the breast care nurse in all stages of the treatment, 321 patients with non-metastatic breast cancer evaluated the contribution of breast cancer nurse to the treatment process. The majority of the participants (87%) reported that the overall contribution of breast care nurses was very high. According to the results of the study, the findings showed that breast care nurses should be included in the multidisciplinary breast cancer team.[16]

In a study evaluating the roles of breast care nurses the as patient advocate, patient trainer, care coordinator and clinical expert roles, conducted by Luck et al. [17] were determined in line with the theme. They reported that breast care nurses have important roles and functions in the maintenance process and the importance of supportive care frequency.

In the first Australian study that defined the role of the national breast care nurse, the role of a breast care nurse in providing information and support to patients was evaluated. The findings showed that training, information and support roles were met from the Australian Specialist Breast Nursing Competency Standards. However, in performing these roles; information- based constraints, time constraints, and barriers to serving large geographical regions were reported in different geographical regions.[18]

Breast Care Nursing in Turkey
In Turkey, although the concept of breast care nursing is not fully settled, the opportunity to organize training programs should be offered in areas specific to nurses caring for cancer patients. In Turkey, many breast care centers serve with a multidisciplinary team. Although there are medical oncology, radiation oncology, general surgery, pathology, radiology, aesthetics and plastic surgery and psychiatrist, physiotherapist and onkopsychologist in the existing centers, there is no breast care nurse in many centers.

The reason for this is thought that the development of these centers is continuing, the lack of an adequate number of nurses who have gained competence in breast care nursing, the inability to determine the role in the team and the lack of a common education program in this field.[19] The role of breast care nurses should be clarified and included as members of multidisciplinary breast cancer teams.

In Turkey, founded in 1989, the Oncology Nursing Association"s "Breast Nursing Sub-Working Group" organizes "Breast Care Nursing "courses every year. Breast Care Nursing course is a program for nurses working in general surgery, plastic and reconstructive surgery, medical and radiation oncology clinics and outpatient clinics and Cancer Early Diagnosis, Screening and Training Center (KETEM), and academicians working in this field.

In addition to the training, the Training of Trainer in Breast Cancer program has been conducted since 2003 by the Oncology Nurses Association to contribute to breast health and breast cancer care. These programs aim to increase the awareness and knowledge of nurses about breast health and breast cancer. In this way, nurses were provided with education in this area, increasing social awareness, updating their knowledge by following new developments and being aware of their professional roles.[20] Training of the Trainer in Breast Cancer includes the training on prevention of breast cancer, treatment, symptom management, and patient care needs. The program includes all nurses working with breast cancer patients. Nurses who complete the training may provide training and counseling to women on the importance of breast health, awareness of breast cancer, and breast cancer risk reduction strategies, and may improve and improve the quality of life in breast cancer patients.[20]

In Turkey in 2013, Marmara University Faculty of Medicine in cooperation with SENATURK (Senoloj Academy) initiated the Breast Nursing Certificate Program (MEHEM). The second program was held in 2015, and the third one was held between October 2017 and January 2018. The program is currently organized for nurses working with breast cancer patients and for nurses working in clinics with cancer patients (general surgery, plastic and reconstructive surgery, medical oncology, radiation oncology, women"s health) who had a bachelor"s degree. The aim of the program is to follow the developments related to breast care nursing with the knowledge, skills and competence that can deliver original nursing care to the patient and family diagnosed with breast cancer, to contribute to multidisciplinary cooperation.[21]

Training standards, accreditation and continuous professional development for breast care nurses should be provided for the quality and evidence-based care of the patients diagnosed with breast cancer. These programs are envisaged to provide certification standards, to be approved by the Ministry of Health and to be expanded in the state, university and private hospitals throughout the country and to contribute to cancer care as cost-effective care. It is recommended that the education of nurses is mandatory and widespread in breast cancer care. Support is needed for the financing and sustainability of the training.

Within the framework of the patient-centered care model, the continuity of care and remote monitoring should also be provided outside the health institutions of the patients. Thus, patients with breast cancer who live in rural and distant residential areas should be able to access the breast care nurse; with the mobile application, e-mobile training and counseling, video conference calls, web-based training and follow- up methods. Various breast care nursing models should be established to provide breast care both in health institutions and outside health institutions. Individualized cancer care and symptom management and psychosocial support should be provided by the breast care nurses and efficient and cost-effective care methods should be supported. In Turkey, specialist knowledge of breast care nurses in the supportive cancer care, skills and competencies that make a significant effect on patient care with quality and cost-effectiveness methodologies are needed to be presented by well-designed scientific studies.

Acknowledgement: This research was presented at the 23.

National Cancer Congress in Antalya in 17-21 April 2019. Peer-review: Externally peer-reviewed.

Conflict of Interest: The authors declare no conflicts of interest.

Financial Support: No financial support has used for the study.

Introduction