My Breast Cancer Story (and What My Fellow Nurse Practitioners Can Learn From It)

In honor of Breast Cancer Awareness Month, former NPWH Board of Directors member Carola Bruflat shares her experience with breast cancer and suggestions for WHNPs with breast cancer patients.

After an 18-year career as a women’s health practitioner, I retired from clinical practice in December 2016. Two months later, on Valentine’s Day, I received a breast cancer diagnosis. What I’ve learned since then may be helpful to those in my profession.

My first phone call after being diagnosed was from the nurse navigator at a large medical center where my husband and I had received care for years. The medical center’s Breast Cancer Clinic answered many questions, but I still felt I needed a second opinion. After all, this was life changing. So, I called one of the physicians at my practice, who became my guide through the process. I am eternally grateful to her.

The breast surgeon was my next stop. She made me feel at ease immediately, drawing diagrams to illustrate the entire process. Together, we chose a partial mastectomy, and the surgery went very smoothly. My margins were clear, and I had no lymph node involvement.

For follow-up, I chose aggressive partial breast radiation. My radiation oncologist had helped to develop this technique and offered a lot of data about side- and long-term effects. But I was not ready for the overwhelming fatigue that resulted, and I also developed oral thrush from using Bactrim and Flovent at the same time. That’s my first lesson for my colleagues: always look at that medication list!

The final part of my cancer journey was to the medical oncologist. I wanted to avoid chemotherapy if possible, and the oncologist reassured me that my choice was valid. Together, we decided on aromatase inhibitor (Aromasin) treatment daily for five years with no chemotherapy. It was a great day when I got that news!

Recently, I had my first mammogram (all-clear), and my first survivorship meeting with the oncology office. I hope my experiences will benefit your patients as we observe Breast Cancer Awareness Month 2018!

Here are some other observations from one who’s “been there”:

What WHNP’s Need to Know

Know and follow the current guidelines for breast cancer screening and risk assessment: Work with your patients to develop individualized plans for screening based on their age, health status, risk assessment and personalized values, and encourage them to take active roles in monitoring their own breast health.

Get a thorough genetic history and update at each visit: As nurse practitioners we are ideally placed to identify families that may have an inherited predisposition to cancer. (My sister developed breast cancer around age 60.) Taking a brief family history can easily become a part of routine health assessments.

Get to know your local breast cancer community and refer patients often to them: Local support groups can be a very important live resource, in addition to websites, message boards, education workshops, counseling programs and online communities.

Listen to your patients: Megan Childers, a nurse practitioner from Vanderbilt University, offers valuable tips here on how to talk to patients with a new diagnosis. They include:

  • Sitting down when you talk.
  • Using simple language.
  • Covering the most important information slowly.
  • Staying positive, calm, personable and empathetic.

Read what is in the everyday press about cancer treatment and new research: Since your patients will surely do so, it’s important to give them good internet sources—those with informative and factual information and stories of hope and reassurance—to look at. I recommend www.breastcancer.org and www.cancer.gov to both patients and practitioners.

My Best Resources

Practitioners may be interested in the results of the TAILORx trial, released in June 2018, finding that most women with early breast cancer do not benefit from chemotherapy.

Please also take a look at this article from The Journal for Nurse Practitioners, April 2018, on managing cancer survivorship issues.

Another great resource is www.breastcancer.org

My Own Personal Insights

  • My mammogram saved my life as I could not feel the lump, nor could anyone else.
  • When you get your diagnosis, learn all you can about breast cancer from reliable on-line sources. It helps you formulate your questions for your first visits, including what your wishes for treatment are.
  • Find your support system – girl friends, spouse/partner, medical partner (my boss), and the nurse navigators. I did not do this very well.   It was so unexpected for me, I found it hard to talk about initially with anyone outside my immediate family.
  • Always get a second opinion – this is cancer after all.
  • Find a medical team you are comfortable with. One of the benefits of being in health care is that as nurses we have the best contacts for care.
  • Choose a healthy lifestyle – be active, eat a healthy/Mediterranean diet, no smoking, limit alcohol, manage stress and other chronic illnesses.
  • Utilize your local support systems and health and wellness programs.

Yes, I am a member of the “1 in 8” club, but I am a breast cancer survivor.

Optimizing Breastfeeding

Outgoing NPWH Board of Directors Secretary Jamille Nagtalon-Ramos, EdD, MSN, WHNP, IBCLC, and Nicole Chaney, MSN, CNM, shares their tips on optimizing breastfeeding below.

WHNPs play a very important role educating and supporting pregnant women and new mothers about breastfeeding. There are many things we can do in both the critical antepartum and postpartum periods to help the mother-baby pair optimize the breastfeeding experience.

As an inpatient WHNP and an International Board Certified Lactation Consultant® (IBCLC®) here’s my guidance for clinicians. Please feel free to share your tips, as well.

Start the Conversation in the Antepartum Period

We should start providing breastfeeding education as early as possible in the pregnancy, according to the “Ten Steps to Successful Breastfeeding” guidelines from the World Health Organization and the United Nations Children’s Fund’s Baby-Friendly Hospital Initiative.

Women are interested in learning about how to best care for themselves and their babies in this period and research shows this is when mothers make their decisions about how to feed their infants. In fact, a mother’s determination to breastfeed during the prenatal period is a strong predictor of successful breastfeeding.

What we can do and say:

  • Find out what’s important to a pregnant patient
  • In my practice, I have found that getting to know my patient and opening up a conversation about what they value and what they fear helps me focus my counseling, For example women with a family history of breast cancer are very interested to know that breastfeeding is thought to decrease the incidence of breast cancer later in life.
  • It’s important to try to identify early on any breastfeeding barriers patients anticipate. You can document those and provide resources to address them at the outset. Then, revisit these barriers periodically throughout the pregnancy.
  • Use open ended questions – as a way of eliciting more comprehensive responses– versus closed questions about feeding options.
  • For example, ask the patient “What would you like to learn about breastfeeding?” rather than “Do you have any questions about breastfeeding?”.
  • Offer a strong statement of breastfeeding support to help influence a woman, while still supporting her personal choice to breastfeed, formula feed, or do both,
  • We can say things like, ”At this practice, we recommend breastfeeding exclusively for the first six months for various health reasons for the baby and for you, the mom.” Organizations like American Academy of Pediatrics recommend it, and I personally recommend breastfeeding,

Teach practice of milk expression

Immediate postpartum can be such a blur (especially with a c/s, pain, anxiety) and can be a tough time for many new moms to learn new things, acquire new skills, and believe that their bodies are capable of making milk to nourish their babies. This is why it’s important to help patients get comfortable with their bodies in the weeks and months before they deliver.

What we can do and say:

  • teach hand expression of milk antenatally. Although not evidenced based, I and other WHNP’s encourage our pregnant patients to practice beginning around 38-39 weeks if they’d like .
  • Most women are comfortable practicing in the shower, but anywhere they are comfortable would work. If they happen to express some milk, they could save it, but you can remind them that most people don’t have milk yet, and that not having expressible milk now has no significance on their body’s ability to make milk after the baby is born.
  • show them the Stanford video
  • encourage women to look in the mirror every day, and tell themselves their body is magical and will make a lot of milk for their baby.

Postpartum Period

In the immediate postpartum period, WHNP’s continue to have a vital role in helping optimize breastfeeding.

What we can do and say:

  • approach each postpartum patient as someone who will be a successful breastfeeding mother unless the patient tells us otherwise.
  • If the patient states that she has decided to formula-feed or to supplement her breastfeeding with formula, I offer the same eager support for her choices.
  • Depending upon the breastfeeding culture of your facility, and your prior knowledge of the patient history, consider asking the brief question, “Did anyone discuss the benefits of breastfeeding with you?”
  • coordinate with the nurses and lactation consultants in your unit on how to work as a team in providing the best possible support for our patients who are open to learning more about breastfeeding

Consider these steps immediately after your patient gives birth:

  • Encourage early (immediate) and unlimited skin-to-skin contact on the mother’s chest, uninterrupted for the first, golden hour
  • Early latching and suckling ??
  • Foster an environment that supports baby-led feeding instead of scheduled feedings.
    • For example, scheduling procedures such as baths, vaccinations, hearing testing around the infant’s feedings and not the other way around.
  • Provide hands-on assistance in helping position the infant especially for the first feeds
  • Teach parents about feeding cues
  • Educate and reassure about expected amounts of inputs – frequency and duration of feedings – and outputs – number of wet diapers.
  • Facilitate obtaining a breast pump through their insurance or rental of the breast pump
  • Educate on breast pump use
  • Educate women who choose to supplement with formula on the types of formula and the preparation of formula
  • Provide culturally-sensitive care for women who desire to breastfeed

Consider these steps prior to patient discharge:

  • Refer women to lactation groups within their community prior to discharge
  • Provide follow-up and telephone support

Think About Your Own Views of Breastfeeding as You Counsel Patients

It is also important for WHNP’s to examine their own personal biases for or against breastfeeding, as well as personal assumptions about cultural, racial, or ethnic influence on a woman’s breastfeeding decisions.

  • consider taking an implicit bias/racism in healthcare training course – because breastfeeding is steeped in historical context, and a person’s own implicit bias can influence their counseling,

Understand Reasons Why Moms Discontinue Breastfeeding Early

As WHNP’s it’s important for us to recognize why nearly 60% of women discontinue breastfeeding at six months and 35% stop at 1 year  – despite the fact that the American Academy of Pediatrics (AAP) recommends that infants be exclusively breastfed for about the first 6 months with continued breastfeeding alongside introduction of appropriate complementary foods for 1 year or longer. (Centers for Disease Control and Prevention, 2018).

Know these major factors that mothers identified as to why they discontinued breastfeeding early:

  • Lack of family support
  • Cultural beliefs and practices
  • Unsupportive hospital practices and policies
  • Concurrent medications while breastfeeding
  • Latching issues