School of Population Health, Research Proposal Example

Abstract

Breast cancer survivors are often experiencing difficulties following highly invasive treatments. According to the American Cancer Society (2013), in 2012 there were a total of 2,971,610 breast cancer survivors in the United States. Survivors’ quality of life is greatly affected by the impact of treatments, and the experience with cancer. Cancer survivors’ well-being has four aspects (American Cancer Society, 2013): physical, psychological, social, and spiritual. The below research proposal would like to focus on two of the above aspects of breast cancer survivors’ well-being: social and psychological. The below study is designed to reveal how the reconstructive tattoo surgery affects breast cancer survivors’ emotional and psychological well-being, as well as their social life.

Rationale

Breast cancer rates in Australia are extremely high, compared with other countries’ statistics (Australian Institute of Health and Welfare and National Breast Cancer Centre, 2006). The statistics also refers to “Australian-born women, with 24.9 deaths per 100,000 females in 2000–2004”, however, mortality rates are declining, and this indicates that there is an increasing need for surgery focusing on survivors’ quality of life. Still, nurse-led areola tattooing is only available in Brisbane in Australia, and this means the availability of the service depends on the work flow of trained surgeons. The below study will investigate whether or not introducing nurse-led breast reconstructive areola tattooing nationwide would improve patient outcomes among breast cancer survivors.

Mastectomy is performed in the early or advanced states of breast cancer. According to Lustombo & Wallace (2010, p. 2), “Breast cancer (BC) is the most common malignancy and second only to lung cancer as the major cause of cancer-related deaths among women in North America and Western Europe”. At the same time, the research performed by Lustombo & Wallace (2010) also confirms that women’s quality of life after mastectomy is reducing women’s confidence level and emotional well-being. The question whether or not cancer survivors’ partners are able to adjust to the results of the surgery is another question that has not been examined in detail below. Nipple tattoo reconstruction is offered for patients as a final phase of reconstructive surgery (American Cancer Society, 2014), usually performed 3-4 months after  mastectomy. Focusing on Australian breast cancer survivor population’s experience with nipple tattoo reconstruction, the author would like to examine the impact of the reconstructive intervention on patient outcomes.

Research Question and Hypotheses

The author of the current study would like to measure patient satisfaction rates among women who underwent NAC tattooing in the areola area. The main focus of the research is based around the following question:

“What are the psychological and emotional effects of nurse led areola tattooing clinical treatments on women surviving breast cancer, and how does the intervention impacts their everyday life, relationships, emotional and psychological well-being? “

The hypotheses the author would like to test based on the results of the qualitative survey carried out among 200 breast cancer survivors who underwent reconstructive surgery, and the final stage:  areola tattooing are as follows:

H1: Patients who survived breast cancer gain self-confidence after the final stage of reconstructive surgery.

H2: Patients’ personal relationships improve following the breast reconstruction and areola tattooing.

H3: Patients’ self image before the areola tattooing is less positive than following the procedure.

Literature Review

Statistics

According to the statistics published by the Australian Government’s Cancer page (2015), breast cancer patients have a 90 percent chance of survival. The Breast Cancer Australia (2012) created a research focusing on the burdens of breast cancer patients, ranking the main causes of distress related to the illness. The leading cause of burden was found to be anxiety and depression. The burdens associated with surviving breast cancer cause premature death, as well as non-fatal health outcomes. Further, the study (Breast Cancer Australia, 2012, p. 65) states that “The burden on females from breast cancer is expected to be concentrated in females aged 40–69, with this disease accounting for 8% of the total burden of disease for females in that age range”.

Intervention overview

Vassileva & Hristakieva (2007, p. 372) states that among breast cancer survivors. “tattooing is now largely performed as a final step in NAC reconstruction as a simple, very effective, safe, and minimally invasive outpatient procedure”. New procedures, such as stencil techniques are currently being experimented (Pauchot et al., 2014). The intervention has a positive impact on every aspect of patients’ lives (Børsen-Koch et al., 2013, Farouk et al., 2015).

Bhatty & Berry (1997) describes the currently used nipple-areola tattooing interventions. Performed by tattoo artists using a cosmetic tattooing kit, the intervention is designed to make the breasts of cancer survivors look as realistic as possible. The position of the nipple is determined using a Silastic nipple prosthesis method. Pigments are mixed by hand, to match the tone of the skin, and anesthetics is performed locally. While nurse-led areola tattooing was introduced in the United Kingdom in 2005, While the procedure is time-consuming, and usually performed by surgeons, their availability limits the number of patients who can receive the intervention. According to the Royal Women’s Hospital (2013, p. 13), “Women who have had a mastectomy have higher rates of depression and thoughts of suicide compared to women who have had a breast reconstruction”, still, only a few hospitals in Australia have trained nurses to perform the cosmetic intervention.

Tan et al. (2015) found that nipple sparing mastectomy is being considered one of the most popular options in Australia, and this study shows that having a nipple is important for both males and females. The same finding was published by Kasem et al. (2014). Another study by Tan et al. (2015) found that offering immediate breast reconstruction after performing mastectomy provided positive outcomes for patients. When patients were informed about their options to have reconstruction intervention after surgery, they were also more likely to take on the treatment. However, the risks need to be addressed, when performing the intervention, such as erythema, infection, and Paget’s disease (Glassy et al., 2012; Hanafiah et al., 2013).

Related studies

The Australian Cancer Survivalship Centre (2012) created a follow-up research of breast cancer survivors. According to the study, survivors can experience several physical, psychological, and practical difficulties. The authors state that there is a need for following up on the lives of survivors, in order to ensure that the negative consequences of treatments related to cancer are addressed and minimised. The National Breast Cancer Centre (Kissane et al., 2006) shows that the most commonly used intervention performed on breast cancer patients were Excision of lesion of breast and simple mastectomy. In 2003-2004, 394 interventions involving the nipple and areola area were performed. In the same years, 4817 simple mastectomy interventions were completed.

One of the main difficulties patients experienced after being treated for breast cancer was lower body image combined with sexual issues (Kissane et al., 2006). Interviews with cancer survivors have shown that “there was limited impact on sexual functioning one-year post surgery”, and the situation worsened over the years. While physically women got adjusted to the loss of breast, they suffered psychologically. Many women, according to the study, experienced “loss of confidence and periods of despair” (Kissane et al., 2006, p. 39, Chen et al., 2005).

Goh et al. (2010) created a patient satisfaction survey focusing on patient evaluation of nipple-areolar reconstruction. The study found that around 80 percent of patients were satisfied with the results, and 89 percent had no complications following the tattooing.

Bhatty & Berry (1997) completed a follow up survey among patients who underwent areola tattooing, and found that the mean time that elapsed between mastectomy and areola tattooing was 21 months, with the shortest time being one month. The mean time that elapsed between nipple reconstruction and areola tattooing was three months. Overall, the study showed a high satisfaction rate among patients who underwent the procedure, and only four patients needed re-tattooing out of the 31 surveyed.

Potter et al. (2006) completed a study about the impact of nurse-led areola tattooing in the United Kingdom, which was introduced in 2005. Until 2005, the procedure was only performed by surgeons. A hundred percent of patients who had nurse-led intervention were satisfied with the tattooing and results, and rated the service excellent. Clarkson et al. (2006) also reviewed patient experiences with nurse-led interventions in the United Kingdom. The authors confirmed the results of Potter et al.’s study, reporting a high satisfaction rate among over 40 patients.

The importance of providing patients with relevant information before the intervention was investigated by Harcourt et al. (2005). The authors of the study used The Body Image Scale, coping type, and information satisfaction. The majority of patients using the nurse-led service were satisfied with both the quality of information provided, and the outcomes of the tattooing.

Methodology

Materials and Methods

The CNS-led service was investigated and patients’ experiences of nipple tattooing were assessed. We present the results of a postal questionnaire and a prospective clinical audit of the procedure. The survey will be carried out among women who survived breast cancer and had mastectomy performed that affected the nipple area. The author of the current research would like to learn how the patients were informed about their choices, whether or not they were offered reconstructive surgery immediately after the operation, and how they feel about the results of the final stage of breast reconstruction: areola tattooing. Qualitative, self-report of patients will be recorded and tested against the above hypotheses, in order to determine areola tattooing’s level of impact on patients’ relationships, confidence, and quality of life. Emotional well-being before and after the areola tattooing will also be measured using an online survey format. SurveyMonkey will be used to record and analyse the answers. Using the 12 Month Patient Survey For Adults (CAHPS®) template (SurveyMonkey, 2015), combined with details about the type of cancer, intervention, and demographic details of participants, the survey will focus on psychological, social, and mental health outcomes of areola tattooing.

The study creator is aiming to get 200 respondents complete the survey, and the follow up survey. One questionnaire link will be sent out to patients who are on the waiting list or have their appointment booked with a specialist for areola tattooing.

The follow-up study will be completed after all patients have under gone nurse-led areola tattooing, and are able to report on their experience, and reflect on their emotional, physical, and social well-being. Patient satisfaction with the service, accessibility, information provided by nurses, and the overall quality of intervention will be recorded. Answers related to emotional, social, and psychological well-being of patient will be compared for the initial and follow-up survey. Further, The Body Image Scale will be utilized to measure the difference before and after the intervention.

Ethical Considerations

Participants will take part in the research voluntarily. They will be provided with an informed consent form, and a short study aim description. They will be informed that they have the right to withdraw from the study at any time, before the results are published. The dignity of participants and their personal information will be respected. The anonymity of nurses and patients will be guaranteed throughout the research.

Timeline

Survey Question Development

The initial survey will focus on three areas: the body image of patients after mastectomy, their emotional and psychological well-being, and the information received prior to the treatments. Using a Likert scale design, the survey will rely on participants’ self-report on the above areas.  The Body Image Scale will also be utilized to measure patients’ satisfaction with their appearance before the cosmetic tattooing.

The follow-up survey will measure emotional well-being and The Body Image Scale will be utilized to measure the variations between patients’ body image prior to surgery and after the completed breast reconstruction, involving the final stage of areola tattooing. Patients will also be asked about the time that elapsed between their mastectomy treatment and the completion of the reconstruction of the breast, in order to find a correlation between waiting times and psychological outcomes.

Data Analysis

Data will be analysed using a method of prevalence testing. The main issues reported by patients will be used to determine patterns. Correlations between scores for self-image, relationship functionality, and confidence will be examined, probing the initial hypotheses that assume that the surgical tattooing has a positive impact on all three areas of breast cancer survivors’ lives. At the same time, satisfaction with the information provided by health care staff, and time elapsed between mastectomy and areola tattooing will be assessed, in order to find a correlation between the above and overall patient satisfaction. Decision regret after areola tattooing will also be measured within the survey, as some authors (Hanafiah et al., 2013) reported changes after reconstruction, such as Paget’s disease.

Rigor

According to Denzin and Lincoln (2000) rigor is associated with trust, authenticity, openness and ethical concerns when constructing research studies. The researcher will ensure rigor throughout by adopting these principles and ensuring the use of credible and quality data sources that are relevant to the research topic. The trustworthiness and quality of research will be achieved through following these principles and the interpretation of the evidencing will be without bias, adhering to the perspective (Denzin & Lincoln, 2000).

Results

Measuring the correlation between self-image and patient satisfaction, the authors found that among the 40 studied women, throughout the population, an overall improvement can be observed. Patients’ satisfaction rate with the nurse-led areola tattooing service was high, and only two women needed further shading within the first six months.

Hypothesis Testing

The author of the current study would like to test the above highlighted hypotheses based on the comparison of data before and after areola tattooing. High self-confidence reports and better relationships, more positive body image scores after the surgery are likely to confirm the hypotheses, and provide health care professionals who are dealing with reconstructive surgery of breast cancer survivors with information about patient burdens, preferences, and expectations.

Conclusion

A nurse-led nipple tattooing service in Australia would certainly benefit breast cancer survivors in many ways. As it has been shown in the research studies carried out in the United Kingdom, satisfaction level is high, patients can have access to full breast reconstruction straight after their surgery, and improve their well-being. By working as a team, specialist nursing units could be able to offer a true breast reconstruction service.

References

Australian Cancer Survivalship Centre. (2012) Follow-up of breast cancer survivors. Retrieved from http://petermac.org/sites/default/files/Education/Follow%20up%20of%20breast%20cancer%20survivors.pdf

Australian Government. Cancer Australia. (2015) Breast cancer in Australia. Retrieved from http://canceraustralia.gov.au/affected-cancer/cancer-types/breast-cancer/breast-cancer-statistics

Australian Government. (2012) Breast cancer in Australia. an overview. Retrieved from http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737423006

Bhatty, M. A., & Berry, R. B. (1997). Nipple-areola reconstruction by tattooing and nipple sharing. British journal of plastic surgery, 50(5), 331-334.

Børsen-Koch, M., Bille, C., & Thomsen, J. B. (2013). Promising results after single-stage reconstruction of the nipple and areola complex. Danish medical journal, 60(10), A4674-A4674.

Chen, S. G., Yu, J. C., & Wang, H. J. (2005). Nipple-areola complex reconstruction after postmastectomy breast reconstruction in Taiwanese females. J Med Sci, 25(3), 125-130.

Clarkson, J. H., Tracey, A., Eltigani, E., & Park, A. (2006). The patient’s experience of a nurse-led nipple tattoo service: a successful program in Warwickshire. Journal of Plastic, Reconstructive & Aesthetic Surgery, 59(10), 1058-1062.

Denzin, N, K., and Lincoln, Y, S., (eds). (2000). Handbook of Qualitative research. Thousand Oaks, California: sage publications.

Farouk, O., Attia, E., Roshdy, S., Khater, A., Senbe, A., Fathi, A., … & Denewer, A. (2015). The outcome of oncoplastic techniques in defect reconstruction after resection of central   breast tumors. World journal of surgical oncology, 13(1), 285.

Glassy, C. M., Glassy, M. S., & Aldasouqi, S. (2012). Tattooing: Medical uses and problems.Cleveland Clinic journal of medicine, 79(11), 761-770.

Goh, S. C. J., Martin, N. A., Pandya, A. N., & Cutress, R. I. (2011). Patient satisfaction following nipple-areolar complex reconstruction and tattooing.Journal of Plastic, Reconstructive & Aesthetic Surgery, 64(3), 360-363.

Hanafiah, M., Alhabshi, S. M. I., & Mahin, A. H. (2013). Changes following nipple areolar complex reconstruction and tattooing resembling a recurrent Paget’s disease of the breast. BMJ case reports,2013, bcr2013201281.

Harcourt, D., Russell, C., Hughes, J., White, P., Nduka, C., & Smith, R. (2011). Patient satisfaction in relation to nipple reconstruction: The importance of information provision. Journal of Plastic, Reconstructive & Aesthetic Surgery, 64(4), 494-499.

Kasem, A., Choy, C., & Mokbel, K. (2014). Skin-Sparing Mastectomy and Breast Reconstruction: An Update for Clinical Practice. Journal of Cancer Therapy, 2014.

Kissane, D., White, K., Cooper, K., & Vitetta, L. (2004). Psychosocial impact in the areas of body image and sexuality for women with breast cancer. The National Breast Cancer Centre.

National Breast Cancer Centre (2006) Breast cancer in Australia: an overview, 2006. Retrieved from http://www.aihw.gov.au/publication-detail/?id=6442467906

Pauchot, J., Fleury, M., Pluvy, I., Oulharj, S., Tropet, Y., & Obert, L. (2015). Stencil technique for areola tattooing. A simple solution for quickly performed, homogeneous tattoos with    regular edges.JPRAS Open, 3, 10-12.

Potter, S., Barker, J., Willoughby, L., Perrott, E., Cawthorn, S. J., & Sahu, A. K. (2007). Patient satisfaction and time-saving implications of a nurse-led nipple and areola reconstitution service following breast reconstruction. The Breast, 16(3), 293-296.

Tan, C., Cao, A., Trinh, L. & Cheung, D. (2015) Uptake of immediate post mastectomy breast reconstruction in a breast unit in Australia. Abstract Journal for Breast Surgery. 2015; 85 (Suppl. 1) 3–13

Tan, C., Cao, A., Trinh, L. & Cheung, D. (2015) Trends in cosmetic considerations influencing surgeon attitudes for nipple sparing mastectomy. Abstract Journal for Breast Surgery. 2015; 85 (Suppl. 1) 3–13

The Royal Women’s Hospital (2013) The Women’s Quality Of Care Report 2013. Retrieved from https://www.thewomens.org.au/images/uploads/main/rwh-quality-of-care-report-2013.pdf

Vassileva, S., & Hristakieva, E. (2007). Medical applications of tattooing. Clinics in dermatology,25(4), 367-374.