When Cancer Affects a Mentally Ill Woman

It gave me great pause recently when I visited the bedside of a patient who had Stage IV breast cancer and was taking lithium for bipolar disorder. I wasn't sure what to expect, but the physician who had asked me to look in on her wished me luck. Hmmm…

Sandra (not her real name) was agitated, angry, and ready to be released from the hospital. She had ignored an early palpable lump until the cancer had consumed the majority of the left breast and had began to fungate. Pathology also revealed positive nodes, and CT scanning illustrated metastasis to the lung. She told me she was not going to have chemotherapy. Her decision was final -- she was not going to lose her hair. She asked me what would happen if she chose to do nothing more. "The surgeon will cut the cancer out, right?" she asked. "Why do I have lung cancer now?"

I explained that she would certainly die without treatment. Since she had moved away from our community and was living at some distance, she was going to need help where she lived, and she owed it to herself to have at least one consult with a medical oncologist and then decide… she could choose. OK, she agreed with me thus far. I went into overdrive to find resources in her new community and a medical oncology group willing to see her and accept her Medicare-only insurance. Then the American Cancer Society was able to assist with Road to Recovery transportation and support groups in her area.

There has been increasing recognition of the high physical morbidity in patients with severe mental illness. Nevertheless, little has been written about cancer in these patients. Severe mental illness is associated with behaviors that predispose an individual to an increased risk of some cancers, including lung and breast cancer, though lower rates of other cancers are reported in this population.

Severe mental illness is also associated with disparities in screening for cancer and with higher case fatality rates. The higher rates are partly due to the specific challenges of treating these patients, including medical comorbidity, drug interactions, lack of capacity, and difficulties in coping with the treatment regimen as a result of psychiatric symptoms. To ensure that patients with severe mental illness receive effective treatment, inequalities in care need to be addressed by all healthcare professionals involved, including those from mental health services and the surgical and oncology teams.

If only we could turn back the clock to earlier in her cancer, but because she had few mammograms and received no follow-up for her small palpable mass 10 months earlier, she undoubtedly had compromised her disease-free interval.

I would love to hear from others about challenging patients and how they were managed, given the importance of reliable, consistent care in this patient population.