Dr. Brooks completed a routine breast exam on Ms Civali and found a suspicious mass. After running necessary tests, Dr. Brooks discovered that Renee Civali has early stage breast cancer. Ms Civali is a 40-year-old, petite woman who is single and works as a successful car salesperson. Ms Civali has been seeing Dr. Brooks for the past 5 years, and chart notes indicate that Ms Civali has been occasionally emotionally unstable and has made most decisions based on what others tell her to do.
Following the diagnosis of breast cancer, Dr. Brooks explained to Ms Civali that she had 2 main treatment options: a total mastectomy or breast-conserving surgery, both options followed by chemotherapy and radiation. Dr. Brooks told Ms Civali that both treatment plans would most likely rid her body of the cancer, but each would carry a specific consequence. Ms Civali, admittedly overwhelmed and unsure of what decision to make, asked Dr. Brooks to make a therapeutic decision on her behalf. Dr. Brooks ultimately suggested the breast conserving surgery and justified the decision by reasoning that this was a less intrusive method with lower chances for a loss of body image, self-esteem, and other psychological issues that often affect younger women with this type cancer. Dr. Brooks believed that, if followed by chemotherapy and radiation, the less radical surgery would achieve the same medical results as the more radical total mastectomy.
Several months after the surgery, chemotherapy, and radiation treatments—all of which appear to have been successful—Dr. Brooks raises the possibility of Ms Civali's beginning an orally administered hormone-based therapy, telling Ms Civali that this could help reduce the risk of the cancer's recurring. Dr. Brooks however, admits to Ms Civali that research suggests that many women may not actually need the hormonal treatment in order to remain in remission because their initial surgery coupled with the follow-up therapies were sufficient. Dr. Brooks explains the various side effects of a hormone-based regimen and states that some women find that the potential benefit is not worth the distressing side effects when there are no signs of aggressive disease. After listening to this proposal, Ms Civali discloses her feelings of depression about the status of her disease and questions whether or not the partial mastectomy was most effective in eliminating her cancer. Ms Civali also acknowledges significant frustration with her current medical situation, saying she feels worn down by the constant trips to the hospital and other reminders of her recent medical history and wishes that she could return to the life she led prior to the discovery of her cancer. After hearing Dr. Brooks discuss the next possible round of treatment and expressing her concerns—both physical and psychological—Ms Civali reports that she is unwilling to make an independent decision with regard to the hormone treatment and asks Dr. Brooks for her recommendation.
This case demonstrates some of the problems that many young women with breast cancer experience. The problems Ms C is having are common reasons for referring a patient with cancer to a psychiatrist.
Only 5 percent of breast cancer occurs in women under the age of 40. Although Ms C was unlucky to have breast cancer at such a young age, her cancer was caught at an early stage, and she was fortunate to have treatment choices. Dr. Brooks had a 5-year relationship with Ms C prior to her cancer diagnosis, is aware of this patient's emotional instability and indecisiveness, and is well positioned to help Ms C continue with her cancer treatment.
Although we don't have precise knowledge about the estrogen and progesterone hormonal receptivity of the tumor, since antiestrogens are being recommended, we can assume that Dr. Brooks has evidence that this regimen can provide a relatively significant benefit to Ms C. Chemotherapy and antiestrogen therapies are frequently described to patients as an "insurance policy" and given that Ms C is a "successful car salesperson" she probably advises her clients about their need for insurance to protect their investment when they purchase a valuable machine, Dr. Brooks may have used this analogy when describing the role of antiestrogens to Ms C. Although Dr. Brooks knows that the most difficult part of Ms C's treatment is behind her, Ms C is feeling overwhelmed and uncertain as to whether she can go on. It's unclear whether she understands that antiestrogen treatment is merely the ingestion of a pill daily, albeit for 5 or more years.
Ms C also appears to be questioning the previous treatment decision and asks Dr. Brooks for another "recommendation." The best advice, I believe, that Dr. Brooks can give is that Ms C consult with a mental health professional (a psychiatrist or psychologist) who specializes in working with women with breast cancer. These professionals, known as psycho-oncologists, commonly consult with women who have just completed surgery, irradiation, and chemotherapy. Many women like Ms C describe feeling depressed, emotionally "worn out," and unable to move forward with their life after 6 to 9 months of cancer treatment. Dr. Brooks will explain that the referral to the psychiatrist is not being made because she thinks Ms C is "crazy," but because she appreciates how long and difficult the treatment has been for Ms C and how arduous breast cancer treatment is for all women. Dr. Brooks knows that starting an antiestrogen immediately is not vital for Ms C's health, and allowing Ms C time to discuss the treatment with another professional may make her more comfortable with her final decision. The psychiatrist also has ample time to: better understand the range of problems that Ms C is struggling with, provide support, treat depression, and, ultimately, help Ms C think through her decision to take or not take an antiestrogen.
When Ms C meets with the psychiatrist, he or she will want to know her family history of breast cancer. Is part of her depression related to the personal tragedy associated with loosing 1 or several family members to breast cancer or other cancers? Is part of the reason she feels depressed or emotionally depleted because she has undergone treatment alone, without enough people available to provide support and practical assistance? Did she continue to work during chemotherapy without telling her employer or business colleagues about her breast cancer because she wished to maintain her privacy?
Dr. Brooks has noted previous emotional instability and a pattern of "making decisions based on what others tell her to do." Many patients ask their doctors to recommend the best treatment and then defer to their physician's clinical judgment. To better understand Ms C's current psychological state, the psychiatrist will ask her about her personal history of depression, anxiety, insomnia, substance use, and her current emotional symptoms. The psychiatrist will also ask how she has made other important decisions in the past. As a successful salesperson, Ms C knows how to "close" or "complete a deal" and must have experience observing others make significant decisions when there is an element of uncertainty. The psychiatrist will probably tell Ms C that Dr. Brooks has really only asked her to start this final phase of breast cancer treatment because, to the best of our current knowledge, doing so will "complete the deal," offering her the best chance of a "cure." The psychiatrist will acknowledge that considering an antiestrogen is difficult when one is overwhelmed, exhausted, depleted, and has decreased ability to concentrate after chemotherapy and then will explain that there are people and strategies available for Mrs. C to use so the decision-making process does not feel so overwhelming.
Ms C is 40, single, presumably without children, and was likely premenopausal prior to chemotherapy. If chemotherapy has made her prematurely menopausal, some of her current emotional distress and depression may be related to fluctuating or reduced estrogen levels and insomnia resulting from vasomotor instability. Part of her concern about antiestrogen use may be her knowledge that some women describe having insomnia, weight gain, and depressed mood when taking antiestrogens, and she may view this as intolerable or worse than her current symptoms.
Maybe Ms C hopes to become pregnant and sees taking 5 years of antiestrogens as dashing an important dream. The psychiatrist will explore her previous plans, thoughts, and hopes about child bearing or child rearing and her current hopes and fears in the aftermath of chemotherapy.
Symptom management to improve Ms C's quality of life will be an important first step before any final decision regarding antiestrogens is made. If her anxiety is severe, the psychiatrist will prescribe a benzodiazepine to manage daytime anxiety and a hypnotic for insomnia. Reducing anxiety to acceptable levels permits many patients to think more clearly and better participate in the decision making process.
Additionally, if Ms C is depressed or has disabling menopausal symptoms, the psychiatrist may prescribe an antidepressant such as fluoxetine, sertraline, paroxetine, or venlafaxine to treat the depressed mood and to reduce the frequency and intensity of hot flashes and night sweats that she may be experiencing.
Although pharmacologic therapy is likely to benefit Ms C significantly, psychotherapy, which has many components including support, will give her a private space in an unhurried setting to voice her frustration, sadness, disappointment, and mourning for the "loss of good health" at a young age. During or after breast cancer treatment younger women commonly want to discuss fears of death, body image concerns, sense of themselves as women, desirability as sexual partners, future sexual relationships, fertility, career, and relationship issues.
In individual psychotherapy, Ms C can discuss her most intimate fears and concerns and how those fears affect her decision making about further treatment. In addition to talking "one-on-one" with a trained professional, many women appreciate the opportunity to participate in support groups for women who are undergoing breast cancer treatment. In a group setting, Ms C is likely to hear other women describe their cancer treatment experiences and say that antiestrogens are, in fact, very tolerable and viewed as an important component of breast cancer treatment to ensure that the cancer "will never come back." Both her psychiatrist and support group members will ask her to think through how she would feel about not trying an antiestrogen if her cancer returned; many women report they would be very disappointed if they had not accepted all anticancer treatment available to them and their cancer recurred. Women who attend breast cancer groups benefit from seeing that they are not alone and that others have and are successfully completing cancer treatment.
In summary, an antidepressant combined with support and encouragement delivered in both individual and group therapy settings are likely to help Ms C feel more in control and better able to think through the pros and cons of future decisions. Dr. Brooks will point out that only rarely does a woman become so uncomfortable on antiestrogens that she chooses to discontinue them. Both Dr. Brooks and the psychiatrist can reassure Ms C that there is good evidence that young women who have been treated for breast cancer achieve good physical and emotional recovery and ultimately have psychological, social, and sexual health equal to that of their peers.
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Massie MJ, Greenberg D. Oncology. In: Levenson J, ed. APPI Textbook of Psychosomatic Medicine. Washington: American Psychiatric Press; 2004:597-618.
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