Paradigm Shifts - Part V

The conceptualization and actual of breast reconstruction has undergone various paradigm shifts depending upon the deeply interwoven historical, societal, medical, and psychological factors at play.

Historically, as mentioned before, breast reconstruction did not really develop and flourish until 1962 when the remains of World War II chemical companies investigated new commercial uses for their products, resulting in medical implants. Women's rights overall in the 1960's and women's health movements specifically in the 1970's & 80's helped to draw attention to the radical mastectomies as the standard
treatment for breast cancer, which were unnecessarily disfiguring, as well as the absence of informed consent
in breast cancer surgery. The passing of the Women's Health and Cancer Rights Act of 1998 instituted principles that - for the most part given insurance coverage - equal opportunity of care and treatment for cancer and reconstruction be available to all women, including those who had been historically marginalized.

From an ontological perspective, within a classic disease model of medicine, cancer is something real that exists and needs to be mapped out, categorized and fully known in an effort to control the disease. Similarly, I would argue an ontological evaluation of breast reconstruction from a medical perspective would propose that the female breast, at its most basic form is a combination of human tissue, skin, and operative features such as mammary glands. However, while reconstruction cannot replicate a fully functioning breast, medicine believes in the creation of a breast form of tissue or implants to represent the physiological natural breast, so appearances remain.  The medical field has developed from entire tissue-removal to eradicate the disease at all costs, to operating under more judicious in attempt to salvage and spare as much as the tissue as possible, while still reducing likelihood of disease, a methodological shift that better served the patients physicians were attempting to help. The healthcare field has also arguably transformed from viewing women as research specimens to working to honor the unique concerns and autonomy each woman brings to the operating table, although the work is not yet complete. While there has been greater emphasis placed upon patient education and patient decision making instead of leaving everything in the hands of medical experts to make life-altering decisions on behalf of the patient, further efforts can still be made to incorporate patients more fully into the treatment planning process.

Within psychology, we have covered the ground in establishing very basic psychological/emotional affective related responses to diagnosis and treatment of cancer, such as higher rates of stress, depression and anxiety and lower rates of self-esteem or body image satisfaction. The field has evolved from that focus into identifying how women arrive at a decision to pursue reconstruction and their level of satisfaction with their choice, including their salient concerns (Harcourt & Rumsey, 2004), perceived necessity of information (Harcourt & Rumsey, 2004; Sheehan, Sherman, Lam, 2007), and contextual factors such as the influence of medical expertise or limited allotted time (Harcourt & Rumsey, 2004; Sheehan, Sherman, Lam, 2007). During that time, the methodology has changed as well in attempts to ground research in theoretical structures (Sheehan et al., 2007) and establish prospective studies (before reconstructive operations occur) to better identify the processes and mechanisms women employ in determining their desire for reconstructive surgery (Harcourt & Rumsey, 2001).

From the beginning of psychology's involvement with cancer treatment, the field recognized that while there was an existent disease, the disease was impacting the person in a multitude of ways were not restricted to physiological health and well-being. Psychology has sought to define and characterize the factors that influence the patient and presumably, the patient's capability to cope or fight the disease. Psychology has also attempted to understand the real experience of battling breast cancer, losing a breast(s), and adjusting to the changes to self-conceptualization that that experience will likely create, by interacting with women in more meaningful ways and engaging in more qualitative work. I propose that recognition of a woman's agency and experience through the cancer experience (which can include the rest of her life) is pivotal to beginning to evaluate and conceptualize the psychological ramifications that a cancer diagnosis can incur.

I valued and connected with the work of Harcourt & Rumsey, because their literature and research is seemingly imbued with a deep compassionate desire to understand the breast cancer experience as best as possible through the eyes of a cancer patient. They did not attempt to pathologize differing coping styles, decision making styles, and satisfaction levels and instead insisted that the provider system should change to fit the patient's needs, not the other way around. Breast reconstruction was evaluated as one of many possible options available to patients and the responsibility fell upon patient care providers to ensure that information was communicated appropriately to the patient and that the emotional support was present. This multifaceted approach for critique and contextual understanding lends me to believe that it closely aligns with critical theory.

Aside from attempting to understand the "lived" experience, critical theorists deal heavily in evaluating how oppression contextually operates and developing methods to disrupt the process. Psychology is already on the path to highlighting ways in which the medical system by and large systemically oppresses patient advocacy in the medical setting. Similarly, critical evaluation of the oppression discourse would not end there; in my survey of the literature I found very limited acknowledgement of the racial or socioeconomic attributes that limit access to reconstruction options. Furthermore, because the very nature of breast cancer targets a gender that has been a historically disenfranchised subset of the US population, it would be useful to psychology to examine if a possible existence of institutionalized sexism may positively or negatively impact patient care. When earlier statistics quote that only three in seven women receive information regarding breast reconstruction (Part IV), is that a result of medical negligence, or other personal or professional biases that may already be in place within the larger healthcare system? Psychology has the capabilities to begin collaborating with women and their experiences to identify where problems and barriers exist.  

Harcourt, D. and Rumsey, N. (2004), Mastectomy patients' decision-making for or against immediate breast reconstruction. Psycho-Oncology, 13: 106–115. doi: 10.1002/pon.711

Sheehan, J., Sherman, K. A., Lam, T. and Boyages, J. (2007), Association of information satisfaction, psychological distress and monitoring coping style with post-decision regret following breast reconstruction. Psycho-Oncology, 16: 342–351. doi: 10.1002/pon.1067