Although 74%–84% of patients with breast cancer who undergo mastectomies are satisfied with their bodies and outcomes after electing to have a flat closure, 20%–35% say that they felt unsupported by their cancer care team during the process. Patients report feeling marginalized or stigmatized, not being told that flat closure is an option, and even left with excess skin against their wishes because the care team wanted to give them “future options.”

Oncology nurses can offer patients with breast cancer electing to have flat closure mastectomies critical support, education, and advocacy, a nurse researcher said in an overview published in the April 2023 issue of the Clinical Journal of Oncology Nursing (CJON). In the article, the author presented the barriers and biases patients face and evidence-based nursing strategies to overcome them.

Flat Closure Mastectomies

More than half of patients with breast cancer do not elect to have reconstruction after mastectomies, and flat closure is one of their nonreconstructive surgical options. During a flat closure procedure, the surgeon “rebuilds the shape of the chest wall after a single or bilateral mastectomy or after the removal of a breast implant or reconstructed breast mound” and “removes excess fat, skin, or other tissues, providing a tightened, smooth, flat chest wall,” the author explained.

Societal and Clinician Biases

The author suggested that requiring insurance companies to cover breast reconstruction after mastectomies under the Women’s Health and Cancer Rights Act of 1998 made reconstruction a societal norm. Although intended to improve access to care and reduce disparities, the author said it “inadvertently prioritized breast reconstruction at the expense of personal preference, leaving some women feeling pressured to undergo reconstruction.”

The societal expectation carries over into the clinical space, too. The author cited various studies where patients felt stigmatized by their care team for not choosing reconstruction, including “one woman who was told that going flat was an ‘unattractive option’ and another who remarked that the nurses and support group facilitators created an atmosphere that promoted reconstruction.”

Evidence-Based Nursing Support

In their roles as patient educators and advocates, oncology nurses can fill the gaps that leave patients feeling unsupported.

Patient education: Overcome a lack of comprehensive information about patients’ surgical options by providing accurate, up-to-date handouts and videos, and coach patients on questions they may wish to ask their surgical team. See the CJON article for a sample handout and sample questions.

The researcher also identified a critical need for nurses to create photo galleries showing a diversity of patients’ flat closures. “These galleries can offer women with various body habitus and breast sizes a better idea of what they may look like after surgery, including incision patterns and tissue or skin restructuring,” the author said. Seeing real examples can help patients understand outcome expectations and psychologically prepare for their body change after surgery.

Decision support: Reinforce your patients’ confidence in their decision to have a flat closure by providing a supportive environment. Examine your own implicit and explicit biases, and encourage the care team to present all surgical options equally without influence or prejudice. Raise your voice as a patient advocate if you believe a patient is being pushed toward reconstruction against their wishes.

Mirror viewing: Well before the flap closure procedure, begin managing patients’ expectations about their experience of viewing themselves in the mirror for the first time after surgery. Ask them when they might want to see their chest and if they want someone to be present when they do. Nursing approaches to prevent mirror trauma include:

  • Because of a potential vasovagal syncope response, prepare for the risk of falls.
  • Ensure patients are in a calm and quiet environment.
  • Use handheld or full-length mirrors.
  • Encourage patients to mirror view their chest daily to establish an accurate new mirror memory and make them more comfortable with seeing their new body in the mirror.

Seeing their new body for the first time after surgery can be an emotional experience. If you’re present for that moment, provide a supportive space and allow your patient to express any emotions they need to.

Psychological support: Some patients embrace their new bodies, scars, and flat closures as reminders of their triumph over breast cancer, whereas others may see the loss of their breasts as a loss of part of their identity, the researcher said. Assess all patients for grief and depression following a mastectomy, and refer any who show signs of psychological distress to a mental health professional for additional evaluation.

For more information and the opportunity to earn 1.0 free NCPD contact hours, read the full CJON article.