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INTRODUCTION
Cancer continues to be one of the leading causes of death in the world 1. It is estimated that its incidence will continue to increase and that 22 million deaths will be recorded in the next two decades 2,3. This indicates that cancer mortality will increase by more than 45% between 2007 and 2030, caused in part by demographic growth and the aging of the population 4. However, its incidence, prevalence and mortality vary in each region and country, and therefore, it is considered a major public health problem worldwide 5.
In 2012 there were about 14 million new cases and 8.2 million deaths related to cancer. The cancers most frequently diagnosed in man were those of lung, prostate, colon and rectum, stomach and liver, in women were breast, colon and rectum, lung, cervix and stomach. More than 60% of the world's new total annual cases occur in Africa, Asia, Central and South America. These regions represent 70% of cancer deaths in the world 6.
The World Health Organization (WHO) reports that the incidence rate of breast cancer increased by 20% between 2008 and 2012, with 1.67 million new cases diagnosed in 2011, which makes it the second type of cancer more common in the world and more frequent among women. The mortality of this type of cancer increased in those 4 years by 14%, with a total of 522.000 deaths in 2012 7.
A statement issued by the Pan American Health Organization (PAHO) in 2012, revealed that in Latin America and the Caribbean there are 27% of new cases of cancer and 15% of these cases were due to breast cancer. In North America, 30% of new cases and 15% of cancer deaths in women were the result of breast cancer. Taking into account this behavior, it is estimated that by the year 2030 there will be more than 596.000 new cases and more than 142.100 deaths from breast cancer 8.
In Colombia, breast cancer is one of the chronic non-communicable diseases that has claimed the most lives. The Ministry of Health and Social Protection says that from 1998 to 2013, the number of women who died of this type of cancer increased by 93.37%. This indicates that around 8.686 cases are detected each year; Most of these are registered in Bogota, Medellin, Cali, Barranquilla, Cartagena, Bucaramanga, Santa Marta and the island of San Andrés 9.
In the Department of Atlántico (Colombia), according to statistics from the National Cancer Institute and the Ministry of Health and Social Protection, the cancer incidence rate between 2007 and 2011 was 481 new cases, the estimated prevalence rate was 1.825 cases, and the observed mortality rate of 12.1% of people diagnosed with breast cancer, with a mortality of 41.5% 10.
The American Cancer Society considers that breast cancer originates when the cells of the breast begin to grow uncontrollably. These cells usually form a tumor that can often be seen on an x-ray or can be felt as a lump. The tumor is malignant (cancerous) if the cells can grow by penetrating (invading) the surrounding tissues or spreading (metastasizing) to distant areas of the body 11.
According to Cano et al.12 cancer is cataloged as a disease that affects the person at the physiological, psychological and social level; it brings with it the idea of suffering and death. Thus, when a person is diagnosed with cancer, she goes through a series of changes and situational crises that break her biopsychosocial balance. In response, the person performs adaptive behaviors that allow her to adapt, overcome and regain her balance again.
Currently, an effective cure for breast cancer has not been found, which implies that patients suffering from this type of disease tend to require interdisciplinary and longterm care, commonly known as palliative care. The nursing professional plays an important role in the management of these patients, because nursing care is the epicenter on which the entire care and the discipline responsible for care revolves during the health and illness experiences of the people 13.
Law 911 of2004 (Code of Ethics of Nursing in Colombia) highlights that the essence of the Nursing profession is the care of health and life, and that this is based on communication and humanized interpersonal relationships between the professional nursing and the human being, family and/or social group, in the different stages of life course, health situation and the environment 14.
This indicates the importance of nursing care in patients with breast cancer, their family and their immediate social environment. For this reason, the present study aimed to show the importance of nursing care in patients with breast cancer in light of the publications reported in the scientific literature.
METHODOLOGY
Anarrative review of the literature was developed in order to achieve the stated objective.
Dixon-Woods et al.15 affirm that the narrative approach is characterized by the selection, chronicle and sequential and contingent order of a certain topic or phenomenon. Mays et al.16 state that the purpose of narrative reviews is to summarize, explain and interpret data on a specific topic or question, an aspect that distinguishes it from a systematic review, insofar as it does not emphasize the search, evaluation and intensive criticism of publications through a rigorous technical protocol, but try to select a certain number of articles, group them according to their results and discuss their approach in light of the methodological characteristics of each to generate general conclusions 17.
Search strategy
Five databases were reviewed: CINAHL, Pubmed, Ovid nursing, Google Scholar and The Cochrane Library, in the period January -April 2017. The key words used were: "breast cancer", "nursing care", "palliative care" and "oncology" which were combined in English and Spanish taking into account the Boolean operators "AND", "OR" and "NOT" and their different synonyms; truncating the terms with (* y $) to specify the search. The established limits were: clinical cases, research and /or revisions published between 2005 and 2017, in English and/or Spanish, and which would have been developed by nursing at home, in oncology or palliative care units.
Search results
During the literature search, 12,800 works were identified. After the revision of titles and abstracts resulted 11,600, after the application of selection criteria and elimination of duplicates resulted in 54 documents, of which 20 were eliminated for not having access to the full text. Additionally, the snowballing technique was applied and 15 studies were obtained, but they were eliminated in duplicates. Therefore, the total of studies selected for this review was 34 works. (Fig. 1)
Source: Prepared by the authors, 2017.
Figura 1 PRISMA diagram of the bibliographic search in databases
The information of the 34 studies included in this work was organized chronologically and synthesized, in order to have an amplified panorama for its interpretation. (Table 2)
Table 1 Subcategories identified in relation to aspects valued by nurses
Source: Prepared by the authors, 2017.
RESULTS
During the review it was observed that of the 34 selected studies, 1 was carried out in Chile 18, 11 in Spain 19-29, 8 in Mexico 30-37, 6 in Brazil 38-43, 4 in Cuba 44-47, 3 in Colombia 48-50 and 1 in Peru 51.
It was identified that 9 studies used theoretical-conceptual foundations of nursing, such as: the theory of transpersonal care 37 and human care of Jean Watson 50, the theory of the end of life of Ruland and Moore 51, the psychodynamic theory of Hildegard Peplau 30, Swanson's Theory of informed care 49, Saunders total pain theory 46, Henderson's theory of 14 basic needs 21, the Adaptation model by Callista Roy 33, the self-care deficit theory Dorothea Orem 31. Additionally, the use of the natural systems theory of Murray Bowen was found 45, although it is a theoretical construct of Psychology, this author cites it frequently in her studies on palliative care in nursing and quality of family life. 45,52.
The remaining 24 studies did not prove to have been guided by any theoretical-conceptual model of reference. When distributing the studies according to the year of publication, it was found that 8 studies were published between 2005 and 2008 18-20,30,38,39,44,48, 15 were published between 2010 and 2013 21-25,31-34,40-42,45,46,49, and 11 were published between 2014 and 2016 26-29,35-37,43,47,50,51.
It is important to highlight that in addition to the findings found with respect to the theoretical framework of reference, 7 studies were framed in the use of the nursing process under the approach of the North American Nursing Diagnosis Association (NANDA), the Nursing Outcomes Classification (NOC) and the Nursing Interventions Classification (NIC) 20,21,25,31,33,35,37. Of the 7 studies, 1 combined the standard language with the functional patterns of Marjorie Gordon 20, and 1 with the 10 processes of Watson's care 37. On the other hand, 1 study showed not having used the nursing process and the Nanda-Noc-Nic taxonomy, but took as a reference the Nursing Care Plan for patients with breast cancer, approved by the Junta of Andalucía in Spain 29.
7 studies were oriented under a qualitative research methodology 33,34,37,40,42,48,51, 9 used quantitative methodology 23,24,30,32,36,38,39,43,47, 7 were reports of successful experiences and clinical cases 19,20,21,25,35,49,50, 10 were bibliographic reviews 18,22,26-29,31,41,44,46, and only 1 developed a mixed-type quasi-experimental study; that is, it combined quantitative and qualitative methodology concomitantly 45.
Identified Categories
From the critical and exploratory review carried out to the 34 selected studies, using colorimetric technique, two large categories emerged that allowed to identify and describe the importance of nursing care in patients with breast cancer. The categories are: a) Aspects assessed by nurses, and b) Approach to nursing care.
Category 1: Aspects assessed by nurses
A total of 7 subcategories were identified as fundamental aspects valued by nurses during the care experience given to patients with breast cancer, these subcategories are listed in Table 1.
The studies reviewed highlight the important role of nurses in providing social, psychological, emotional and family support required by patients who have been diagnosed or have breast cancer, whether in the early, middle or late stages of the disease 18-20,22,28,29,38,48.
Below are some descriptive fragments for the identification of subcategories:
"The role of the nurse is not only related to treatment and cure, but also to establish preventive measures (...), to control the conditions of the patient and to provide guidance, emotional support".38
"Due to the broad role that nurses perform, (...) We provide advice and support during rehabilitation and reintegration into their daily lives".18
"Therefore, in 2002, a nursing consultation was created (...), with the aim of providing post-surgical care and psychological support, while providing the necessary information in a progressive, personalized and an appropriate environment".19
"Social and emotional support can help patients learn to cope with psychological stress. This support can reduce levels of depression, anxiety and symptoms related to the disease and treatment".28
Such support can be provided by nursing, psychology, medicine or social work personnel during the pre-surgical and post-surgical phases. However, it is more effective if it is provided in an integral way at an interdisciplinary, even multidiscipli-nary level 18-20,22,29,38,44,48.
".......the woman who is going to undergo a mastectomy needs a support network and guidance and interventions made by a multidisciplinar/ team, with high participation of nursing staff, because the preoperative care and how they are performed as well as the necessary orientations play an important role in the recovery"38
"It is necessary to give more emphasis to the multi professional visit in the preoperative period, since the entire health team can contribute to the adaptation of the patientS first and then in their rehabilitation"38
"The multidisciplinary clinical care session is one of the interventions that can improve the effectiveness of the care provided (...)"20
"In our center, Hospital de Palamós (Girona), (...) was formed by a multidisciplinar/ team of gynecologists, radiologists, pathologists and oncologists, (...)"19
"On the other hand, a multi and interdisciplinary team, enhances the coping activities of patients with the disease".29
Self-care and the proactive attitude of women with breast cancer is an aspect addressed by nursing professionals, because it helps in the process of cancer recovery and improvement of well-being, as well as the reduction of costs and institutional expenses 18,20,30,31.
"This process aims to achieve, in short, that women of different ages understand the importance of knowing their breasts; encourage self-care and a proactive attitude regarding the health of their breasts".18
"The patient is informed that most of them are transient, vary in intensity according to the individual response, and are given practical recommendations to reduce them, as well as the tools for self-care".18
"An appointment is scheduled at home with the community liaison nurse and the family nurse to assess the knowledge the patient has about her illness and subsequent self-care, and to monitor the treatment regimen of her previous pathologies.".20teaching them how to stay healthy, can generate a population responsible for self-care that does not depend too much on hospital care and, therefore, leads to lower costs and greater benefits for society and institutions".30
"....a nursing care plan, (...) to guarantee quality care, meet present health problems, strengthen the capacity for innate self-care in each of the individuals and achieve early readjustment to society".31
It is important to emphasize that in order to achieve self-care behavior and a proactive attitude, it is necessary that nurses provide information and education to the patient and evaluate each stage of the process 19,23,35.
"One of the main objectives of nursing is to provide education and detailed information on all those risk factors; besides stimulating the adoption of healthy habits for the patient and teaching the proper technique of self-exploration of breasts".35tionally supporting and educating women with breast cancer".23
Taking into account that breast cancer involves a set of emotional and psychological affectations in the patient, the nursing professionals see it necessary and pertinent to evaluate the level of coping, stress and degree of adaptation that the patients may acquire 29,33.
".........nursing will improve the care and coping of the patient's illness".29
"The nurse plays an important role, can help those suffering from cancer in the process of coping with pain as part of their pathological process and contribute to saving energy to be used in the recovery of the disease". (29)
".....nurses, can fulfill their objective of promoting the adaptation of the person as a goal of nursing in thefour areas, (physical-physiological, self-concept, Role mastery and Independence)".33
Another important aspect identified in the studies is related to the assessment of spiritual well-being and the interpersonal relationships of the patient who experiences the disease 30,31,34,37,49. Therefore, some of the studies reviewed highlight the work of nursing in the approach to the spiritual dimension of the person.
"It is important to mention that in the study population everyone feels able to obtain a well-being in depth, giving the guidelines to provide specific nursing intervention for the strengthening of spiritual well-being".30
"In the consultation (nursing) for post-surgical "For being a pathology that originates physical, cures, information tasks, health education psychological and social changes; the nursing staff and psychological support are performed".19must be able to meet all these needs in order to help the individual to maintain their independence "...it would be timely and necessary to train in the evolutionary process of their illness and nurses specialized in specific care aimed at emo- in turn, strengthen their biopsychosocial and spiritual health".31
"The Process of Care, based on a theory of nursing, makes it possible to articulate science and technology with spirituality and love for the improvement of the quality of life of women who experience breast cancer".49
"...implies that nurses facilitate spiritual-centered communication harmoniously during caregiving, (...)......Therefore, integrating spirituality into nursing care allows society to contribute to the preservation or searchfor harmony in women who experience breast cancer".34
"Implementing a nursing process under this perspective of transpersonal care allows the development of a conscience of care (...) which facilitates that the woman with breast cancer reaches a remarkable degree of harmony in her mind, body and spirit".32
Quality of life and satisfaction of breast cancer patients are two aspects that also emerged in the review of the 34 studies. Achieving quality of life in people with cancer is an unavoidable objective for nursing and the rest of the health team 23,44,49.
"......the nursing professional plays a fundamental role in this area (quality of life), since many objectives are achieved to a great extent with the comprehensive care of the work of the multidisciplinary team".44
"The Process of Care, based on a theory of nursing, makes it possible to articulate science and technology with spirituality and love for the improvement of the quality of life of women who experience breast cancer".49
"Improving the quality of life of women with breast cancer constitutes an independent field of activity for the nurse discipline".23
Most studies are focused on the management and control of unpleasant signs and symptoms derived from breast cancer, as well as the proportion of education to the patient and caregivers about how to control them. Among the clinical manifestations, the most approached are the control and relief of physical signs and symptoms 20,21,22,25,28,33,35,46,50,51, the psychosocial symptoms 21,22,24,27,28,30,46,50,51, and alterations in the skin 25,26,39.
Category 2: Approach to nursing care
For the identification of the approach, a classification of the studies according to the nursing approach was made to the sick person of breast cancer and the main family caregiver as the immediate context of the affected person. In this sense, it was found that of the 34 studies analyzed, 26 are aimed at people with the health problem 18-28,30,31,33,35,37-39,41-42,44,46,48-50, 3 are aimed at family caregivers 32,45,47, 4 were directed towards the nursing staff 29,36,40,43, and only 1 approached patients, primary caregivers and nursing staff concomitantly 51. It is important to highlight that those studies in which the patient was approached, was done from clinical perspectives. However, it is striking that the approaches of the studies do not include the family.
DISCUSSION
Cancer, and specifically breast cancer, is a process of great emotional impact both for the disease itself and for the physical and emotional consequences that it entails 24. The literature shows that breast cancer is the most common cancer pathology among women worldwide, and is increasing especially in developing countries 23,22,31. That is why early detection, in order to improve prognosis and survival, continues to be the cornerstone of the fight against this type of cancer 23,22.
This has turned professional care into an important social requirement, as well as an ethical imperative for health professionals 20,31; especially, Nursing professionals, who stay longer and establish greater contact with this type of patients 54-57, besides being the most numerous within the health institutions 58,59. This situation makes these professionals have the need to look for new and better mechanisms of approach that allow them to achieve their objective: to take care of health and life 53. In this sense, Arguelles and Fernández 26 affirm that it is important that nursing care be provided with the best possible quality, in order to avoid complications derived from the disease However, to provide quality care, the nursing professional requires extensive knowledge about comprehensive palliative care 36,43.
According to Muñoz-Torres et al.31 the complexity of the physical, psychological and social changes that breast cancer encompasses requires that Nursing personnel have the capacity to meet all these needs in order to help the individual maintain their independence in the evolutionary process of his illness and in turn, strengthen his biopsychosocial and spiritual health.
Olea et al.34 with words of Jean Watson, affirm that the nursing professional must adopt the perspectives of human care to better approach the patient, and Urra et al.60 state that in the care of this type of patients it is fundamental to preserve the human essence and reposition the care within the health systems. This is because the psychological impact that women experience as a result of the diagnosis and treatment of breast cancer is not ephemeral 22.
According to Almeida et al.40 another important aspect that should be strengthened in the practice of palliative care is the therapeutic communication between the nursing professional, patients and the family. This interrelation must be configured in a nursing situation, in which the flow of experiences and shared life allows transforming the meaning of nursing care in the context of the disease.
Some authors affirm that nursing professionals give meaning to their practice in the light of other theoretical contexts and conceptual frameworks that are not nursing 61. However, this review shows that when nursing care is provided under theoretical foundations of reference and systematic methodological frameworks, the results could have a greater impact on the health of patients with breast cancer. In this regard, Hernández 49,50 affirms that the process of care, based on a nursing theory, makes it possible to articulate science and technology, and also allows the integration of the emotional and social dimension with the biological, leading to personal and professional growth in the nurses.
The use of nursing methodology has been a subject on which the effectiveness of care has been demonstrated. Authors such as Ortega et al.35 affirm that the application of the Nursing Care Process allows nurses to provide care in a rational, logical and systematic way. However, these methodologies would have greater impact, if family caregivers and the family in general were included. Ostiguin et al.32 assert that it is necessary to recognize the primary caregiver as an important figure in the health system, by accepting their potential and limitations to assume responsibilities in the care task in the health institution as well as in the home.
Borré-Ortiz et al.62 maintain that the care of the sick person in the home is provided by a primary caregiver or the family, but that in turn, the family requires educational, psychological, spiritual, emotional and social support systems that allow it to maintain its stability, balance and potentiality; confirming what was expressed by Canga et al.63 and Vivar 64 who affirm that it is important that health professionals have a systemic vision of the family and be considered as a unit of care.
In addition to the psychological, emotional and spiritual aspects valued by nurses, this review found a strong tendency towards the care of physical symptoms. This is consistent with what is expressed by Expósito, who affirms that adequate control of symptoms is part of the essence of Palliative Care. 45.
Lafaurie et al.48 recommend that educational processes should be focused on the greater understanding of cancer by women with breast cancer, in addition to guiding them to know self-care strategies that help them to minimize their symptoms and the effects of their treatments. In this same sense, Carvalho 41 proposes that the actions necessary to achieve effective palliative care are related to health education, in which the nurse should encourage the participation of the female user of the health service, encouraging self-care in performing the clinical examination of the breasts ; considering that nursing has a preponderant role in the development of actions with the population, since the focus of their work is humanized care, focused on the prevention of grievances and the promotion of health.
CONCLUSION
Nursing care in patients with breast cancer continues to be a permanent challenge that requires nursing professionals not only to have clinical competencies for the management of symptoms, but also demand competencies for the educational, emotional, family, psychosocial and spiritual approach. Additionally, this approach represents a challenge in the use of disciplinary knowledge to be able to demonstrate the usefulness it has in the improvement of the nursing care process.
On the other hand, the literature continues to demonstrate the importance of the human, dignified and palliative nursing care required by breast cancer patients. Therefore, it is necessary that nursing care be more comprehensive and strengthened in the light of interdisciplinarity. However, it is suggested to continue developing the body of scientific knowledge, increasing research in this field, to improve the quality of care offered to patients diagnosed with breast cancer and, therefore, their quality of life, satisfaction and well-being; both individually and familiar.
