Monday 21st December 2015
Mac Voice, the magazine for Macmillan professionals: Winter 2015
The fith part of this Sharing Good Practice issue on psychological support: Rachel Criddle on how she supports shared decision-making.
As a Macmillan clinical psychologist, part of my role involves supporting patients, their families and the breast care team in making decisions with regards to risk-reducing mastectomies (RRM).
There are two types of risk-reducing mastectomy: bilateral (BRRM) or contralateral (CRRM). A BRRM is the surgical removal of both breasts to help reduce the risk of developing breast cancer, which is carried out even though there is no evidence of cancer in the breasts. A CRRM is for women with a strong family history of breast cancer and/or who have cancer in one breast and decide to have the other breast removed to reduce the chance of getting breast cancer again.
My experience to date has been working with patients considering having a CRRM. While the aim of the mastectomy is referred to as ‘risk-reducing’, in my experience (see case studies) and as indicated by evidence , patients’ reasons for wanting an RRM are often multifaceted and go further than this. The decision as to whether to have an mastectomy is a serious and significant one. It is a large operation which cannot be reversed, and like all surgery has its own risks.
There are also additional considerations, such as whether to have a reconstruction or whether to wear prostheses. For this reason, it is important that the psychological implications of this procedure are considered. It's important that the patient’s psychological suitability is assessed, and that the decision-making process of the patient, their family and the breast cancer team is supported.
The psychologist enables this by providing the patient with a safe and reflective space to explore their choices, thoughts, feelings, motivations and expectations, so they can make the best informed decision for their situation. The psychologist typically meets with the patient for an hour and a half for one to two sessions. The session is done jointly with a breast care nurse so that they can answer any medical questions about the procedure and recovery and also to clarify the patient’s understanding about their risk of developing cancer or a recurrence. Prior to and at the beginning of the session, it is also important to provide information on the psychologist’s role in the process.
The patient is also sent the Macmillan guide Understanding risk-reducing breast surgery. Following the session, the psychologist provides written feedback (as discussed and agreed with the patient) to the referrer.
Case study one
Mrs P was referred by one of the breast surgeons. She said she was considering an RRM to reduce the risk of getting cancer in her other breast, and that she was mainly doing this for her daughter, because she did not want her to have to go through it again.
We explored Mrs P’s decision thoroughly, looking at both the advantages and disadvantages of having the surgery. We concluded that it seemed this was not the best time for her to be making this decision, as she did not feel emotionally stable enough to do so – she needed more time to recover, process and come to terms with her cancer experience. Mrs P also said she felt she would not be able to cope with the emotional and psychological aftermath of having an RRM.
We agreed it may be a good idea to give her time to see whether she could cope and live with the uncertainty of a cancer recurrence. I suggested she could try attending our Living with Uncertainty group. We agreed the best outcome would be to ask for her RRM to be postponed, until she felt in a more emotionally stable place to make an informed decision.
I wrote back to the breast surgeon making the recommendation. Following this, a decision was made by the surgeon and Mrs P to postpone the surgery for eight months. During this period Mrs P decided she did not want a RRM and cancelled the surgery.
Case study two
Mrs D was referred by one of the breast care nurses. Mrs D told me she was 100% sure and determined to have the surgery. Mrs D told me her main reason for wanting an RRM was to reduce the risk of her getting cancer again. Mrs D said she believed having an RRM would mean she could move forward with her life, as she would no longer have to worry about getting cancer in her other breast. She also said she wanted an RRM to restore symmetry.
Mrs D and I also talked about the disadvantages to having an RRM. She initially said she could not think of any. As we discussed this further, however, we outlined disadvantages, including the risks and complications of surgery, and the long recovery. She said she also realised that this will not stop cancer recurring elsewhere. I also highlighted that it is therefore unlikely to completely get rid of the fear of recurrence.
However, Mrs D said she still felt that the advantages far outweighed the disadvantages. She was not concerned about further surgery. She said she coped with it previously and knew what to expect. She also said she would have plenty of support from her family and her workplace. She told me her previous mastectomy had not had a significant impact on her body image, feelings of femininity or sexuality. However, we talked about managing her expectations, as it may take time for her to adjust to having both breasts removed and the resulting change in appearance.
I wrote to the consultant, stating Mrs D’s reasons for wanting a RRM seemed largely driven by her desire to reduce her feelings of vulnerability to a recurrence, and to regain trust and a sense of control in her body. Secondly, it seemed that she would like this surgery to achieve symmetry. I stated Mrs D appeared to have given this a lot of thought and was realistic in her expectations, and it seemed she would be able to cope psychologically with surgery and the recovery. In summary, the decision as to whether to have a RRM is a serious and significant one for all involved in the process, including patients, families and professionals.
It is important that patients are provided with a safe and reflective space to fully explore all elements of this decision, and to make informed choices. Clinical psychologists aid and support this process, and ensure patients' emotional and psychological well-being is kept central.
1 Beesley H et al. Risk, worry and cosmesis in decision-making for contralateral risk reducing mastectomy. The Breast. 2013. 22: 179–184.
2 Pan Birmingham NHS Cancer Network. Guidelines for the Multidisciplinary Management of Patients Considering a Risk Reducing Mastectomy. 2012.
3 Pan Birmingham NHS Cancer Network. Psychology Services for women considering risk reducing mastectomy: a patient information leaflet. 2008.
Email Dr Rachel Criddle, Macmillan Clinical Psychologist Cwm Taf University Health Board.
Continue reading Sharing Good Practice
Part 1: Psychological support - Dr Anne Johnson, Macmillan Consultant Clinical Psychologist, Velindre Cancer Centre.
Part 2: Evidence base - Janice Rees, Macmillan Consultant Clinical Psychologist, Cardiff and Vale University Health Board.
Part 3: Acceptance and Commitment Therapy - Dr Claire Delduca, Macmillan Clinical Psychologist, Velindre NHS Trust.
Part 4: Helping parents with cancer support their children - Dr Claire Delduca, Macmillan Clinical Psychologist, Velindre NHS Trust.
Part 5: How a clinical psychologist can support shared decision-making - Dr Rachel Criddle, Macmillan Clinical Psychologist, Cwm Taf University Health Board.
Part 6: Psychological supervision for staff - Dr Rachel Criddle, Macmillan Clinical Psychologist, Cwm Taf University Health Board.
Part 7: Extend your psychological support skills - Resources and training for professionals.