YO31 - “Their voices are louder than yours, doctor” Unspoken challenges managing breast cancer in a schizophrenic patient: a case report.

Case summary

“Their voices are louder than yours, doctor”

Unspoken challenges managing breast cancer in schizophrenia: a case report.

Managing cancer patients with schizophrenia remains a challenge to many oncologists.

In September 2021, a 62-year-old female with schizophrenia, presented with locally advanced right breast cancer, hormone receptor-negative, HER2 positive, cT4bN0M0. She had breast surgery in December 2021 and completed 2 cycles of adjuvant chemotherapy and radiotherapy, which then she defaulted. In September 2022, she relapsed in the nodes and lungs. She was counselled for chemotherapy and trastuzumab but her auditory hallucination tells her to not have trastuzumab. After discussion with her family, she finally agreed and received 1 cycle of paclitaxel and trastuzumab in October 2022. Unfortunately, she defaulted again. In February 2023, she developed contralateral breast masses. She initially refused trastuzumab. However, after no response with 5 cycles of paclitaxel, she finally agreed to anti-HER2. She was given gemcitabine and trastuzumab and remained stable until June 2023.

This case illustrates the multi-level challenges in providing cancer treatment for patients with schizophrenia. Due to mental disabilities, they might not be aware of their symptoms early, thus can delay the first presentation. Other challenges are communication barriers, treatment adherence, access to social support groups, and counselling skills. With regard to this case, we acknowledge that counselling her for systemic therapy has been challenging. The start of anti-HER2 treatment has also been delayed multiple times. A meta-analysis reported SMI individuals receive less / delayed standard of care for breast cancer than the general population (1). Soft skills in counselling schizophrenic patients were not incorporated into national oncologic training and remain an unmet need. In conclusion, it is important for oncologists to be aware of these challenges and employ a comprehensive approach.

1) Kisely S. Breast cancer treatment disparities in patients with severe mental illness: A systematic review and meta-analysis. Psychooncology. 2023 May;32(5):651-662.

Clinical trial identification

Editorial acknowledgement