Subject Area: Surgery & Surgical Specialties
1. Introduction
Today, cancer diagnosis and treatment with addressing multidisciplinary become a multi-faceted issue. Clinical guidelines state that multidisciplinary team is to understand the patient’s condition, reduce the patient’s anxiety and depression, increasing self-esteem, improving general health condition and reducing the somatic symptoms and to manage breast cancer in best way [1] . The breast care nurse is a constant member of the multidisciplinary team, provides diagnosis of breast cancer, shows necessary care to women in treatment and rehabilitation, and provides information and support. After surgical treatment of cancer, externally visible impairment of an organ and the change of body appearance can lead to disastrous consequences for patients as psychologically. In many societies, women’s breasts represent femininity, sexuality, aesthetic appearance, infant feeding, feelings of love, and motherhood. Therefore, women with breast cancer as a result are having severe psychological and spiritual problems, such as feelings of the deterioration body image, reduced self-esteem, the thought of losing femininity, the idea of decreasing sexual function, anxiety, depression, hopelessness, guilt and shame, fear of repeating, isolation and death fear [2] - [4] .
2. Evaluation of Patient with Breast Cancer and Breast Reconstruction
The reconstruction performed after mastectomy, while it provides the body image of women, it influences the overall self-esteem in a positive way [5] . The breast reconstruction, after the excision of the breast tissue in an appropriate manner, yet it means to volume the lost breast with a suitable material/leather flap replacement. After mastectomy performed for breast cancer, formal reconstruction techniques are known for more than 50 years [6] . In general, every woman who is to be made or going to have mastectomy, as being a candidate for breast reconstruction, while deciding about reconstruction they may need a breast care nurse. Therefore, infor- mation about breast reconstruction should be given to the mastectomy surgeryto-be applied/applied patients.
Breast care nurse must be there for each patient’s psychological status, be able to assess the response by the diagnosis and must value the information requirements, must give adequate emotional support and help. In addition, method of coping with patient’s diagnoses and decision-making capacity should be monitored from the moment of diagnosis in order to understand the physical and psychological condition of the patients, and each step has to be evaluated separately.Breast care nurses must help the patient to recognize the diagnosis, methods to help the patient fully understandthe treatment and to help the patient to decide about reconstruction or for another option [5] - [7] .
3. İnforming the Patient about Breast Reconstruction and Decision-Making Process
The purpose of informing the suggested womanabout breast reconstruction; is to help make decisions about the planning of these operations simultaneously, and to prepare the patient toattempt the surgery and after the process [5] [8] . When giving information to the patient you need to be sensitive towards the personal needs. While the reasons that lead to identical and late breast reconstruction can be different, simultaneous requirements of a woman may be different fromthe planned. Information should go beyond simple explanations and should be explained in a way that leads people to ask questions. In addition, spouses, family, and friends should be in- cluded in discussions if appropriate. Specific information about reconstruction and how it will affect the quality of life should be given to the patients. Giving the information to the patient, does not mean that everything is understood by the patient, it is important to assess whether the information is understood by the patient [5] [8] [9] .
Issues that create anxiety in the patient should be put forward and the spots that concerns or the mis- understanding of the patient should be focused on to figure out and elucidate [3] [10] . Information is difficult to understand in a single meeting, in the next meeting should be repeated by the surgeon or a breast care nurse. It is important that the breast care nurse to be present in the first meeting according to know what is being discussed between the surgeon and the patient and to value that the patient has understood everything that is said clearly. Surgeon and the breast care nurse working together is providing the continuity of information that is given [5] . After being used to working together, the given information are becoming properties that complete each other. An important point of giving information about the breast reconstruction process is also, the creation of realistic expectations.It should be indicated that the patient will never have a new breast; but will have a much better simulated image and shape. The satisfaction of patients after surgery is related to prior expectations before attempting; bygivingthe realistic information to the patient disappointment will be prevented. When discussing about breast reconstruction, non-surgical procedure options should also be informed to the patients. Today, different types of external breast prostheses are available, patients should be informed about them. During the interview, the use of drawings and photographs are very useful. Here, photographs are not giving the best results, it is the objective information that belongs to variable results [5] [11] [12] .
Providing information to the patient is a previous stage of the decision-making process. To determine the pre- ferences of patients and enable them to accompany the decision-making process, it requiresgood communication skills supported by the information materials [3] [5] . If the patient participates actively in the decision-making process, the anxiety and depression levels decreases. However, patients who do not want to participate in this case must be carefully evaluated and must always be at the forefront of the patient’s request. Patients who leave the decision-making responsibility to someone else should be respected and should support the ones who want to actively participate in decision-making process [3] [10] . Breast care nurses helping patients about why they need such a surgery, should provide a balanced perspective about breast reconstruction. In particular, in the reconstruction it should notbe decided of the partner’s request. Breast care nurse plays an important role about patients understanding and being sure of the motivation and expectations related to reconstruction [5] [8] .
While a surgeon tells if the patient’s reconstruction indication is appropriate, the patient should give the final decision. It is important to clearly understand what reconstruction process means for women and about realistic expectations should be informed to the patients [5] . Breast care nurse is playing an important role of the woman during the decision-making process, should be open empathy and should be communicating with the patient based on trust. Also, by detecting the situation well, should know which decisions to focus on, it is important to support issues that exist in the description of each option that is offered and should support the surgeon about what questions to ask. Many women perceives breast nurses as people that who understand their emotional changes and supports them from their perspective during the decision making process [5] [8] [13] .
4. Psychological Effects of Reconstructıon and Body Image
Patients tend to see reconstruction as part of the rehabilitation stage of the cancer. Therefore, reconstruction proposal is pointing to a better prognosis, and can be perceived as a positive situation. Thought of reconstruction, is to pull the patients attention to another direction from the disease, rescuing from the feeling of losing body image and to make the patient think that is entering the healing process [6] . Women with more reconstructive surgery expectations are in need of more information before surgery. While the process of adjustment in chang- ing the body has began,to help overcome after surgery easily, preparation for surgical interventions in women is very important. Body image plays a particularly important role in adaptation to social life and disease. Breast care nurse’simportant part of role is to provide information and support of patients in making decisions on reconstruction. Regular exchange of information should be provided in order to be useful in patients between breast care nurse and surgeon. Breast care nurses should be impartial and should provide counseling services about patient’s information needs. In addition, they should be prepared for the patient’s question “what you would do if you were in this situation?” [5] [8] [13] .
Especially prior to surgery, giving enough information and support for emotional aspects of women feel more satisfaction from reconstructive cosmetic results [12] [14] . Usually the ones who are not realistic in the begin- ning and who have lots of expectations, or facingunexpected complications cannot be satisfied with the result. Therefore, it is important to demonstrate only the realistic expectations. Using a variety of photos and brochures of information is helping to understand the women’s expectations and to prepare for the surgery. Photos of cos- metic results should be shown before surgery [5] [13] . Rowland and friends emphasizes thatdoing reconstructive, is to make others happy or thehigh possibility of disappointment in women who wants to fix a relationship that is not going well [15] . This process of being very traumatic in terms of physical and emotional, breast care nurses should give the necessary information and support the patients.
There may be many reasons why woman request reconstruction. Most of the women feel a strong desire towards wanting to feel normal again and to return to their old way of life as possible. For some women, to meet this need with an external prosthesis, but for others surgical reconstruction may be possible. Reconstruction will be successful for patients with an absence of breast thought of struggle [5] [12] . With reconstruction, patients feel more comfortable with the body image, increasing self-esteem and can be able to see herself as a woman again. Women thus feel that they retain their attractiveness; even relationships that do not go well with some women think that reconstruction will save them [12] [14] . It is thought that there is a close link between body image and sexuality [3] [16] . Poor body image leads to avoidance behavior in sexuality in healthy women and men. Breast reconstruction in the case of loss associated with breast after mastectomy being directly sexual, would have women to feel better physically and mentally, and it should be noted that it contributes positively to sexual health [5] [12] [13] .
Body image and self-esteem of breast cancer plays an important role ofdeciding the type of surgery that will be applied. While some women does not want to use prosthetic wantssimultaneously reconstruction, and after some start using prosthetic reconstruction ask forlate-timed to get rid of it. When breast implants are seen from the outside, as it is seen that it is largely put in place by the loss, it helps women feel a sense of integrity, it does not preventthe distortion of body image, and it repairs the lack of corruption and sense of missing. As a result, some women have expressed that external prosthetic presence is a constantly factor that is reminding them of the disease [5] [8] [9] [13] .
Breast care nurse, informswomen whom thinks of bilateral prophylactic mastectomy, and giving information about breast reconstruction plays an important role. For women with high risk for breast cancer, this form of treatment is an option. Prophylactic mastectomy has showed that it significantly reduces the risk of breast cancer [17] . In addition, the reduction of concerns about the development of breast cancer, such as relaxation of the patient psychologically and socially have positive results. However,this should be evaluated of the surgery by taking both the physical and emotional side effects in account and in terms ofmaking-decision without turning back. A breast care nurse, with the multidisciplinary team, with or without reconstruction, bilaterally prophy- lactic mastectomy, which is thought for women, plays a crucial role in providing the best information to women. Support should be in the decision of all the appropriate option for the treatment of patients, time should be given to the patients to think and to prevent a quick decision. For this group of women, breast reconstruction provides significant psychosocial benefits that should be routinely offered to patients [13] [18] .
5. Is the Age İmportant for Reconstruction?
For women who are seeking reconstruction, age is not a negative factor that affects this situation. The feeling of loss of the breast in patients regardless of age can lead to serious problems and it is difficult to accept the impaired body image [5] [19] . For elderly patients who cannot express the request of the reconstruction easily, it is important to receive suitable support from the patients’ family and friends. Again, some patients, regardless of age, cannot choose reconstruction because of the potential risks of surgery, complications and uncertainty in cosmetic results. Some patients believe that it may adversely affect the survival of the breast reconstruction after surgery, and that they can ruin the strategy. A thought of cosmetic surgery can be unnecessary; they can reject the suggestion of reconstruction for healing physically and psychologically [5] [8] [9] . In the study performed by Zieli?ski et al. on 73 patients between the ages of 37 - 79, the reasons for patients to reject the reconstruction were specified as the existence of a second surgical intervention, feeling of severe pain and its negative influences on the cancer treatment [20] .
Even if women disagree with their spouses and children, it may be the best way for them to evaluate options and to decide which one is the most appropriate for their needs. Besides being newly diagnosed, the patient’s anxiety and fear will cause the patient to have difficulty during the decision process. During the decision-making process, if the patient has taken more responsibility and if things do not go right as expected, anxiety may be more severe. In such cases, if the results are not like what they have expected, the patients must be convinced that they have no personal guilty. Enough time should be given to the patients in order to make the final decision. The final decision for many patients is evaluated by many factors of reconstruction’s positive aspects, such as preservation of femininity, self-confidence and charm [3] [5] [13] .
As a result, the incidence of breast cancer has been increasing nowadays. In this context, the needs for breast care nurses are increasing as well. Breast care nurses play an important role for the protection of women’s breast health, development, providing both physical and psychosocial recovery. Counseling support given to women by breast care nurses will provide emotional support, and help them to deal with the problems they may face, to ease the decision-making process, and to affect the quality of life in a positive way after the surgery.