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  1. Free E-newsletter
  2. What to Know About Triple Negative Breast Cancer Treatment | SELF
  3. VARIOUS TYPES AND MANAGEMENT OF BREAST CANCER: AN OVERVIEW
  4. Second opinions and second chances
  5. Search form

The seeds will be put in using long needles and X-rays to guide the doctor. The number of seeds used depends on your type of tumour. The seeds are left in place and slowly release radiation over several months. The treatment is usually completed in a single visit. After the procedure: Once the procedure is finished, you will be taken to a room to recover until you are fully awake.

You will usually be discharged from hospital the same day once you have had something to eat and drink. Arrange for someone to bring you home. It is best not to drive for at least 12 hours afterwards. You will need to take antibiotics for a few days afterwards to prevent any infection. Before you leave, you will be given the contact details for the hospital and a follow-up appointment as well. This is used mainly to treat cancers in the head and neck area, the cervix, womb, prostate or the skin.

High dose rate HDR brachytherapy involves a temporary implant of radioactive material the source. Tubes called applicators are put into your tumour under general anaesthetic so that the radioactive source can reach the tumour. The radioactive source stays close to or inside the tumour between 5 and 15 minutes, sometimes you may need a few treatments a week apart.

In some hospitals the applicators are left in place between treatments. Once the treatment is over the tubes are removed. For cancer of the thyroid, the radiation source may be unsealed or open. It involves using a liquid source of radiation called a radionuclide radioisotope. It can be given as an injection into a vein but is more usually taken by mouth as a capsule. Unsealed sources are radioactive until your body gets rid of them. Before treatment you will be brought to a special room with an en-suite. Here you will be asked to take a capsule of radioactive iodine.

You will have to stay in this room for a number of days as your urine and stools will be radioactive. Usually after three days you will be allowed home. Your doctor, nurse or physicist will advise you on any precautions that need to be taken about this type of treatment.

How much treatment you receive will depend on the size, location and type of cancer. Your treatment will be planned to suit your situation. Even patients with the same type of cancer may have different radiotherapy treatments. Your doctor will discuss this with you. With external radiotherapy, treatment can last from 4 to 8 weeks.

With LDR brachytherapy , you will have one visit to put the seeds in and they stay in permanently. With HDR brachytherapy you may need only 1 treatment. In general, radiotherapy is safe. Depending on the type of radiotherapy you receive, you may have to take some special precautions. Although the seeds are radioactive, you are not. It is fine for you to be among people. But you do need to be careful around women who are pregnant and young children. It is fine for you to give them a quick hug or to be in the same room as them. But it is best not to allow children to sit on your lap or sit next to a pregnant woman for long periods of time for two months after treatment.

You may have to stay in hospital for a few days. Certain safety measures will be taken to prevent exposing hospital staff and your friends and relatives to radiation. Once the treatment is over, there is no risk of harming your family or friends with radiation. For more information on the side-effects of radiotherapy please see our page on the side-effects of cancer treatments. Freephone to talk to a specialist cancer nurse.

It's open Monday-Thursday from 9am to 6pm and Friday from 9am to 5pm. By email: cancernurseline irishcancer. Know what to expect when you're going through cancer treatments. Living with cancer can affect all areas of your life. Find out ways we can provide practical and emotional support to cancer patients, their loved ones and carers. Email us. Online community. Irish Cancer Society Daffodil Centres provide in-person, one-on-one cancer information, support and advice in local hospitals across Ireland.

Find a Daffodil Centre. At the Irish Cancer Society we aim to provide quality practical support to people who are affected by cancer and their friends and family. In order to ensure that we are doing this, we would like to hear about your experience of using our website. Your voice is really important and your feedback will help make a difference. All you need to do is click on the link and fill out a short 5 minute survey. The results will be anonymous but will really help us improve our service. Take survey.

Jump to Navigation. Irish Cancer Society. Questions or concerns about cancer? Search form Search. Donate now. Cancer information What is cancer? What is radiotherapy? Radiotherapy can be given on its own or with surgery, chemotherapy , hormone therapy or monoclonal antibody therapy. It can be given before surgery to shrink the tumour or after surgery to treat any residual disease. Radiotherapy can be given from outside the body externally or from inside internally. Radiotherapy in general is safe.

Depending on the type of radiotherapy, you may need to take special precautions after treatment. Radiotherapy may cause side effects that can last for a short or a longer period. When you may need radiotherapy Your doctor may prescribe radiotherapy to destroy the tumour: this is called curative radiotherapy. Types of radiotherapy There are different ways to give radiotherapy. External beam radiotherapy Giving radiotherapy externally is called external beam radiotherapy and a course can last 4—8 weeks. The different types of external beam radiotherapy include: Conformal radiotherapy 3D Intensity-modulated radiotherapy IMRT Stereotactic radiotherapy Conformal radiotherapy This is also called 3D conformal radiotherapy.

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External radiotherapy treatment visits Your first visit to the radiotherapy unit will be for planning purposes only. Treatment visits You will visit the radiotherapy unit each weekday with a rest at weekends. Internal radiotherapy is given in 2 main ways: Putting radioactive seeds or rods inside your tumour used in the treatment of prostate , cervical and endometrial cancer As radioisotopes to treat thyroid cancer.

There are 2 types of brachytherapy , depending on the dosage: Low-dose-rate LDR brachytherapy High-dose-rate HDR brachytherapy LDR brachytherapy This involves putting radioactive seeds directly into your tumour and leaving them there permanently. The DIEP free flap takes tissue from the abdomen and the surgeon attaches the blood vessels to the chest wall.

Gluteal free flap. The gluteal free flap uses tissue and muscle from the buttocks to create the breast, and the surgeon also attaches the blood vessels. Because blood vessels are involved with flap procedures, these strategies are usually not recommended for a woman with a history of diabetes or connective tissue or vascular disease, or for a woman who smokes, as the risk of problems during and after surgery is much higher.

The DIEP and gluteal free flap procedures are longer procedures and the recovery time is longer. However, the appearance of the breast may be preferred, especially when radiation therapy is part of the treatment plan. Talk with your doctor for more information about reconstruction options. When considering a plastic surgeon, choose a doctor who has experience with a variety of reconstructive surgeries, including implants and flap procedures, and can discuss the pros and cons of each procedure.

An external breast prosthesis or artificial breast form provides an option for women who plan to delay or not have reconstructive surgery. These can be made of silicone or soft material, and fit into a mastectomy bra. Breast prostheses can be made to provide a good fit and natural appearance for each woman. Removal of cancer in the breast: Lumpectomy or partial mastectomy, generally followed by radiation therapy if the cancer is invasive. Radiation therapy may or may not be used if it is DCIS. A mastectomy may also be recommended, with or without immediate reconstruction. Women are encouraged to talk with their doctors about which surgical option is right for them.

Also, talk with your health care team about the possible side effects from the specific surgery you will have. More aggressive surgery, such as a mastectomy, is not always better and may cause more complications. The combination of lumpectomy and radiation therapy has a slightly higher risk of the cancer coming back in the same breast or the surrounding area. However, the long-term survival of women who choose lumpectomy is exactly the same as those who have a mastectomy.

Even with a mastectomy, not all breast tissue can be removed and there is still a chance of recurrence. Women with a very high risk of developing a new cancer in the other breast may consider a bilateral mastectomy, meaning both breasts are removed. Although the risk of getting a new cancer in that breast will be lowered, surgery to remove the other breast does not reduce the risk of the original cancer coming back.

What to Know About Triple Negative Breast Cancer Treatment | SELF

And more extensive surgery may be linked with a greater risk of problems. Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. There are several different types of radiation therapy:. External-beam radiation therapy. This is the most common type of radiation treatment and is given from a machine outside the body.

Intra-operative radiation therapy. This is when radiation treatment is given using a probe in the operating room. This type of radiation therapy is given by placing radioactive sources into the tumor. Although the research results are encouraging, intra-operative radiation therapy and brachytherapy are not widely used. Where available, they may be options for patient with a small tumor that has not spread to the lymph nodes.

Learn more about the basics of radiation therapy.


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A radiation therapy regimen, or schedule see below , usually consists of a specific number of treatments given over a set period of time. Radiation therapy often helps lower the risk of recurrence in the breast. If there is cancer in the lymph nodes under the arm, radiation therapy may also be given to the same side of the neck or underarm near the breast or chest wall. Adjuvant radiation therapy is given after surgery.

VARIOUS TYPES AND MANAGEMENT OF BREAST CANCER: AN OVERVIEW

Most commonly, it is given after a lumpectomy, and sometimes, chemotherapy. Patients who have a mastectomy may not need radiation therapy, depending on the features of the tumor. Radiation therapy may be recommended after mastectomy if you have a larger tumor, cancer in the lymph nodes, cancer cells outside of the capsule of the lymph node, or cancer that has grown into the skin or chest wall, as well as for other reasons.

Neoadjuvant radiation therapy is radiation therapy given before surgery to shrink a large tumor, which makes it easier to remove. This approach is uncommon and is only considered when a tumor cannot be removed with surgery. Your doctor can recommend topical medication to apply to the skin to treat some of these side effects. Very rarely, a small amount of the lung can be affected by the radiation therapy, causing pneumonitis, a radiation-related swelling of the lung tissue.

This risk depends on the size of the area that received radiation therapy, and this tends to heal with time. In the past, with older equipment and radiation therapy techniques, women who received treatment for breast cancer on the left side of the body had a small increase in the long-term risk of heart disease. Modern techniques are now able to spare the vast majority of the heart from the effects of radiation therapy. Many types of radiation therapy may be available to you with different schedules see below. Talk with your doctor about the advantages and disadvantages of each option.

After a lumpectomy. Radiation therapy after a lumpectomy is external-beam radiation therapy given Monday through Friday for 3 to 4 weeks if the cancer is not in the lymph nodes. If the cancer is in the lymph nodes, radiation therapy is given for 5 to 6 weeks. This often starts with radiation therapy to the whole breast, followed by a more focused treatment to where the tumor was located in the breast for the remaining treatments.

This focused part of the treatment, called a boost, is standard for women with invasive breast cancer to reduce the risk of a recurrence in the breast. Women with DCIS may also receive the boost. For women with a low risk of recurrence, the boost may be optional. It is important to discuss this treatment approach with your doctor. After a mastectomy. For those who need radiation therapy after a mastectomy, it is usually given 5 days a week for 5 to 6 weeks.

Radiation therapy can be given before or after reconstructive surgery. Even shorter schedules have been studied and are in use in some centers, including accelerated partial breast radiation therapy see below for 5 days. These shorter schedules may not be options for women who need radiation therapy after a mastectomy or radiation therapy to their lymph nodes.

Also, longer schedules of radiation therapy may be needed for some women with very large breasts. More research is being done to find out whether younger patients or those who need radiation therapy after chemotherapy may be able to have these shorter radiation therapy schedules. Partial breast irradiation. Partial breast irradiation PBI is radiation therapy that is given directly to the tumor area instead of the entire breast.

It is more common after a lumpectomy. Targeting radiation directly to the tumor area usually shortens the amount of time that patients need to receive radiation therapy. However, only some patients may be able to have PBI. Although early results have been promising, PBI is still being studied. It is the subject of a large, nationwide clinical trial, and the results on the safety and effectiveness compared with standard radiation therapy are not yet ready.

This study will help find out which patients are the most likely to benefit from PBI. PBI can be done with standard external-beam radiation therapy that is focused on the area where tumor was removed and not on the entire breast. PBI may also be done with brachytherapy by using plastic catheters or a metal wand placed temporarily in the breast. Breast brachytherapy can involve short treatment times, ranging from 1 dose to 1 week. It can also be given as 1 dose in the operating room immediately after the tumor is removed.

These forms of focused radiation therapy are currently used only for patients with a smaller, less-aggressive, and lymph node-negative tumor. Intensity-modulated radiation therapy. Intensity-modulated radiation therapy IMRT is a more advanced way to give external-beam radiation therapy to the breast. The intensity of the radiation directed at the breast is varied to better target the tumor, spreading the radiation more evenly throughout the breast. The use of IMRT lessens the radiation dose and may decrease possible damage to nearby organs, such as the heart and lung, and the risks of some immediate side effects, such as peeling of the skin during treatment.

This can be especially important for women with medium to large breasts who have a higher risk of side effects, such as peeling and burns, compared with women with smaller breasts. IMRT may also help to lessen the long-term effects on the breast tissue, such as hardness, swelling, or discoloration, that were common with older radiation techniques.

IMRT is not recommended for everyone. Talk with your radiation oncologist to learn more. Special insurance approval may also be needed for coverage for IMRT. It is important to check with your health insurance company before any treatment begins to make sure it is covered. Proton therapy. Standard radiation therapy for breast cancer uses x-rays, also called photon therapy, to kill cancer cells. Proton therapy is a type of external-beam radiation therapy that uses protons rather than x-rays.

At high energy, protons can destroy cancer cells. Protons have different physical properties that may allow the radiation therapy to be more targeted than photon therapy and potentially reduce the radiation dose. The therapy may also reduce the amount of radiation that goes near the heart. Researchers are studying the benefits of proton therapy versus photon therapy in a national clinical trial.

Currently, proton therapy is an experimental treatment and may not be widely available. Recent research studies have looked at the possibility of avoiding radiation therapy for women age 70 or older with an ER-positive, early-stage tumor see Introduction , or for those women with a small tumor. Overall, these studies show that radiation therapy reduces the risk of breast cancer recurrence in the same breast, compared with no radiation therapy.

However, they note that women with special situations or a low-risk tumor could reasonably choose not to have radiation therapy and use only systemic therapy see below after lumpectomy. This includes women age 70 or older and those with other medical conditions that could limit life expectancy within 5 years. People who choose this option must be willing to accept a modest increase in the risk that the cancer will come back in the breast. Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body.

Systemic therapies are generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication. Common ways to give systemic therapies include an intravenous IV tube placed into a vein using a needle, an injection into a muscle or under the skin, or in a pill or capsule that is swallowed orally.

Each of these therapies are discussed below in more detail. A person may receive only one type of systemic therapy at a time or a combination of systemic therapies given at the same time. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects. It is also important to let your doctor know if you are taking any prescription or over-the-counter medications or supplements.

Herbs, supplements, and other drugs can interact with cancer medications. Learn more about your prescriptions by using searchable drug databases. It may be given before surgery to shrink a large tumor, make surgery easier, and reduce the risk of recurrence, called neoadjuvant chemotherapy.

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It may also be given after surgery to reduce the risk of recurrence, called adjuvant chemotherapy. A chemotherapy regimen, or schedule, usually consists of a combination of drugs given in a specific number of cycles over a set period of time. Chemotherapy may be given on many different schedules depending on what worked best in clinical trials for that specific type of regimen.

It may be given once a week, once every 2 weeks also called dose-dense , once every 3 weeks, or even once every 4 weeks. There are many types of chemotherapy used to treat breast cancer. Common drugs include:. A patient may receive 1 drug at a time or a combination of different drugs given at the same time. Research has shown that combinations of certain drugs are sometimes more effective than single drugs for adjuvant treatment.

The following drugs or combinations of drugs may be used as adjuvant therapy for early-stage and locally advanced breast cancer:. AC or EC epirubicin and cyclophosphamide followed by T doxorubicin and cyclophosphamide, followed by paclitaxel or docetaxel, or the reverse. An example is the antibody trastuzumab. Combination regimens for early-stage HER2-positive breast cancer may include:. The side effects of chemotherapy depend on the individual, the drug s used, and the schedule and dose used.

These side effects can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, diarrhea, constipation, early menopause, weight gain, and chemo-brain. These side effects can often be very successfully prevented or managed during treatment with supportive medications, and they usually go away after treatment is finished. Rarely, long-term side effects may occur, such as heart damage, nerve damage, or secondary cancers such as leukemia and lymphoma.

Talk with your health care team about the possible side effects of your specific chemotherapy plan. Hormonal therapy, also called endocrine therapy, is an effective treatment for most tumors that test positive for either estrogen or progesterone receptors called ER-positive or PR-positive; see Introduction.

This type of tumor uses hormones to fuel its growth. Blocking the hormones can help prevent a cancer recurrence and death from breast cancer when used either by itself or after chemotherapy. Hormonal therapy may be given before surgery to shrink a tumor, make surgery easier, and lower the risk of recurrence. This is called neoadjuvant hormonal therapy.

It may also be given after surgery to reduce the risk of recurrence. This is called adjuvant hormonal therapy. Tamoxifen is a drug that blocks estrogen from binding to breast cancer cells. It is effective for lowering the risk of recurrence in the breast that had cancer, the risk of developing cancer in the other breast, and the risk of distant recurrence.

Tamoxifen works well in women who have been through menopause and those who have not. Tamoxifen is a pill that is taken daily by mouth. It is important to discuss any other medications or supplements you take with your doctor, as there are some that may interfere with tamoxifen. Common side effects of tamoxifen include hot flashes as well as vaginal dryness, discharge or bleeding. Very rare risks include a cancer of the lining of the uterus, cataracts, and blood clots.

However, tamoxifen may improve bone health and cholesterol levels. Aromatase inhibitors AIs. AIs decrease the amount of estrogen made in tissues other than the ovaries in postmenopausal women by blocking the aromatase enzyme. This enzyme changes weak male hormones called androgens into estrogen when the ovaries have stopped making estrogen during menopause. These drugs include anastrozole Arimidex , exemestane Aromasin , and letrozole Femara. All of the AIs are pills taken daily by mouth.

Only women who have gone through menopause or who have had medicines to stop the ovaries from making estrogen see Ovarian suppression, below can take AIs. Treatment with AIs, either as the first hormonal therapy taken or after treatment with tamoxifen, may be more effective than taking only tamoxifen to reduce the risk of recurrence in post-menopausal women. The side effects of AIs may include muscle and joint pain, hot flashes, vaginal dryness, an increased risk of osteoporosis and broken bones, and increased cholesterol levels.

Research shows that all AIs work equally well and have similar side effects. However, women who have undesirable side effects while taking an AI may have fewer side effects with another AI for unclear reasons. Women who have not gone through menopause should not take AIs, as they do not block the effects of estrogen made by the ovaries.

Often, doctors will monitor blood estrogen levels in women whose menstrual cycles have recently stopped, or those whose periods stop with chemotherapy to be sure that the ovaries are no longer producing estrogen. Ovarian suppression. Ovarian suppression is the use of drugs or surgery to stop the ovaries from producing estrogen. It may be used in addition to another type of hormonal therapy for women who have not been through menopause. There are 2 methods used for ovarian suppression:.

Goserelin Zoladex and leuprolide Eligard, Lupron are types of these drugs. They are given by injection and stop the ovaries from making estrogen for 1 to 3 months. The effects of GnRH drugs go away if treatment is stopped. Surgery to remove the ovaries, which also stops estrogen production. While this is permanent, it can be a good option for women who are done having children, especially since the cost is typically lower over the long term. Tamoxifen for 5 years, followed by an AI for up to 5 years. This would be a total of 10 years of hormonal therapy.

Tamoxifen for 2 to 3 years, followed by 2 to 8 years of an AI for a total of 5 to 10 years of hormonal therapy. In general, women with stage I cancer should expect to take hormonal therapy for 5 years. As noted above, premenopausal women should not take only AIs, as they will not work. Options for adjuvant hormonal therapy for premenopausal women include the following:. Tamoxifen for 5 years. Then, treatment is based on whether or not they have gone through menopause in those 5 years.

If a woman has not gone through menopause after the first 5 years of treatment, she can continue tamoxifen for another 5 years, for a total of 10 years of tamoxifen. If a woman goes through menopause during the first 5 years of treatment, she can continue tamoxifen for an additional 5 years or switch to an AI for 5 more years.

Only women who are clearly postmenopausal should consider taking an AI. For women with stage I or stage II cancer with a higher risk of recurrence who may consider also having chemotherapy. For women who cannot take tamoxifen for other health reasons, such as having a history of blood clots. Ovarian suppression is not recommended in addition to another type of hormonal therapy in the following situations:. This information is based on ASCO recommendations for adjuvant endocrine therapy for women with hormone receptor-positive breast cancer.

Please note this link takes you to another ASCO website. These treatments are very focused and work differently than chemotherapy. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells. Not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor.

In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them.

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Learn more about the basics of targeted treatments. The first approved targeted therapies for breast cancer were hormonal therapies. This drug is approved as a therapy for non-metastatic HER2-positive breast cancer. Currently, patients with stage I to stage III breast cancer see Stages should receive a trastuzumab-based regimen often including a combination of trastuzumab with chemotherapy, followed by completion of 1 year of adjuvant trastuzumab.

This risk is increased if a patient has other risk factors for heart disease or receives chemotherapy that also increases the risk of heart problems at the same time. These heart problems may go away and can be treated with medication. Pertuzumab Perjeta. This drug is approved for stage II and stage III breast cancer in combination with trastuzumab and chemotherapy. Neratinib Nerlynx. This oral drug is approved as a treatment for higher-risk HER2-positive, early-stage breast cancer. It is taken for a year, starting after patients have finished 1 year of trastuzumab.

Ado-trastuzumab emtansine or T-DM1 Kadcyla. This is approved for the treatment of patients with early-stage breast cancer who have had treatment with trastuzumab and chemotherapy with either paclitaxel or docetaxel followed by surgery, and who had cancer remaining or present at the time of surgery. T-DM1 is a combination of trastuzumab linked to very small amount of a strong chemotherapy.

This allows the drug to deliver chemotherapy into the cancer cell while lessening the chemotherapy received by healthy cells. T-DM1 is given by vein every 3 weeks. Talk with your doctor about possible side effects of specific medications and how they can be managed. Bone modifying drugs block bone destruction and help strengthen bone. They may be used to prevent cancer from recurring in the bone or to treat cancer that has spread to the bone.

Certain types are also used in low doses to prevent and treat osteoporosis. Osteoporosis is the thinning of the bones. For people with breast cancer that has not spread, receiving bisphosphonates after breast cancer treatment may help to prevent a recurrence. ASCO recommends zoledronic acid Zometa or clodronate multiple brand names as options to help prevent a bone recurrence for women who have been through menopause.

Clodronate is only available outside of the United States. Please note that this link takes you to a separate ASCO website. You may have other targeted therapy options for breast cancer treatment, depending on several factors. Many of the following drugs are used for advanced or metastatic breast cancer. These drugs include abemaciclib Verzenio , palbociclib Ibrance , and ribociclib Kisqali. They are approved for women with ER-positive, HER2-negative advanced or metastatic breast cancer and may be combined with some types of hormonal therapy.

It may be combined with the chemotherapy capecitabine, the hormonal therapy letrozole, or the HER2 targeted therapy trastuzumab. Larotrectinib Vitrakvi for breast cancer with an NTRK fusion that is metastatic or cannot be removed with surgery and has worsened with other treatments.

Immunotherapy, also called biologic therapy, is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. Atezolizumab Tecentriq. In , the US Food and Drug Administration FDA approved a combination of atezolizumab plus protein-bound paclitaxel see Chemotherapy, above for locally advanced triple-negative breast cancer that cannot be removed with surgery and metastatic triple-negative breast cancer.

In addition, it is only approved for breast cancers that test positive for PD-L1 see Diagnosis. Pembrolizumab Keytruda. This is a type of immunotherapy that is approved by the FDA to treat metastatic cancer or cancer that cannot be treated with surgery. Different types of immunotherapy can cause different side effects. Common side effects include skin reactions, flu-like symptoms, diarrhea, and weight changes. Talk with your doctor about possible side effects for the immunotherapy recommended for you. Learn more about the basics of immunotherapy. Age should never be the only factor used to determine treatment options.

Systemic treatments, such as chemotherapy, often work as well for older patients as younger patients. However, older patients may be more likely to have side effects that impact their quality of life. For example, older patients may have a higher risk of developing heart problems from trastuzumab. This is more common for patients who already have heart disease and for those who receive certain combinations of chemotherapy.

They should also ask about potential side effects and how they can be managed. For people of all ages, cancer and its treatment can cause symptoms and side effects. This approach is called supportive or palliative care , and it includes supporting the patient with his or her physical, emotional, and social needs.