1) CASE SUMMARY
Madam SMA is a 41-year-old lady who was diagnosed with advanced left breast carcinoma with metastases to the bone and lung (T4N2M1) two months ago, was admitted for her first cycle of chemotherapy of FEC regime (5-Fluorouracil, Epirubicin and Cyclophosphamide).
She has features of Major depressive disorder of moderate intensity such as anhedonia and depressed mood for the past 1 month with biological features of insomnia, psychomotor retardation, loss of weight and appetite, lethargy, poor concentration, guilt and sense of worthlessness and hopelessness when she was first diagnosed to have advanced malignancy of the breast and was told that her treatment is only palliative. She also has significant impairment in occupational, social and functioning but no suicidal ideation. She also have social withdrawal as she refuses to spend time with her friends and relatives who came to visit her especially to her 4 young children where she pushed them away when they want to spend time with her.
Mental state examination revealed a low mood and depressed affect. There was also reduced amounts of speech and loss of concentration. She has poor insight but good judgment.
She had no complications after her first cycle of chemotherapy. She was discharged uneventfully and had appointment for her following chemotherapy sessions. There is no other intervention done at the current moment. A psychiatric referral should be made and she should be started on anti-depressants to improve the quality of life.
History of Present Illness
She was first diagnosed with left breast carcinoma in September 2009 where she presented with fracture of the left humerus on a trivial injury. She accidentally hit her left arm on the wall when she wanted to carry her baby up. She noticed it was swollen immediately and she felt pain in her left arm and could not move her left arm up. She was admitted to Orthopaedics Department in Hospital Batu Pahat for four days where a u-slab was applied to the left arm and the causes of the pathological fracture of the left humerus were investigated.
She complained of having a left breast lump for more than a year when she was 8 months pregnant. She noticed that the size of the lump was initially about 1 cm and hard in consistency. She told her findings to the doctor during her antenatal check up but was reassured that it was benign and most likely to be due to a mammary gland. After she has delivered her baby, she went for her post-natal check up at the local clinic and she was again reassured that the breast lump was due to a mammary gland as she was lactating at the time. Six months later she went to private practitioner because the breast lump was increasing in size to more than 2 cm but she was again told by the doctor that it was due to a mammary gland and it was benign. She continued to breastfeed her child with no problems. There was no inversion of nipples, bloody or pus discharge from the breasts and the amount of breast milk was equal on both sides.
In the orthopaedics ward, a surgical referral was made and an urgent ultrasound and trucut biopsy of the breast lump was done. The breast lump had progressively increased in size, hard in consistency, and associated with pain and left nipple distortion. The ultrasound and the biopsy results revealed features suggestive of malignancy of the left breast. She was then referred to the Hospital Sultan Ismail Johor Bahru in October for radiotherapy of her left humerus followed by chemotherapy for the breast carcinoma before proceeding with mastectomy of the left breast.
She complained of dry cough associated with chest pain especially worsen at night which disturbed her sleep occasionally for the past few months. She also has malaise, poor appetite associated with significant weight loss of 10 kilograms in the past 6 months. She had no history of headache or seizure.
Madam SMA has been having low mood for the past one month. This occurred after she was diagnosed with left breast carcinoma. Her low mood is worse in the morning and would improve slightly as the day progressed. She previously enjoys reading children stories to her children when she has time. However, ever since she was diagnosed with cancer, she stopped reading to them. She also complained of pain at the left breast occasionally. When she feels pain at her left breast, she will just sit in her chair or lie in her bed and not do anything. Her husband also noticed she was more slowed in her daily activities such as responding to his conversations, or moved about slowly in the house.
She also developed depressive cognitions. She had feelings of hopelessness. She was told that she had advanced malignancy and the doctors can only treat her to make her comfortable. As the doctors cannot cure her cancer, she felt that there is no hope in living her life any longer. She will not be able to be a part of her 4 children's future as she cannot she her children grow up.
Madam SMA also feels guilty that she is ill and blames herself for not being firm when she suspected that her breast lump was not a benign condition when she previously went to see the doctors multiple times. Her guilt is further confounded by the fact that her children are still young especially the youngest who is only 1-year-old. They are unable to care for themselves. She feels guilty that it is her fault and this will put a lot of burden on her husband who a lorry driver. She is a housewife and a home-based tailor who provides extra earnings for the family income. Their combined income was about RM 3000. Ever since she was diagnosed with breast cancer, most of their savings has been used to pay for her medical bills and she no longer is able to contribute to the family income as her has stopped tailoring. She can still do some tailoring but she feels tired all the time therefore she had stopped. Hence, she feels that she will be unable to support her children in their education in the future. She also feels that her life is worthless and that she would be less of a burden to her husband if she were to die.
There is also social withdrawal as she hardly responds to her siblings and friends when they call or come to visit her. Her husband noticed that she is often irritable and occasionally scolds her children for small reasons. Although she does worry about their children because they are so young without a mother when she dies, she still feels that her children should start getting used to not having her around. Hence, she often pushed her children away when they want to be with her.
Madam SMA has somatic signs such as weight loss, lethargy and insomnia. She has problems falling asleep when she has a persistent dry cough associated with chest pain at night. On nights where she is able to sleep and does not cough, she had problem maintaining sleep and also early morning awakening. Symptoms of poor appetite, weight loss and lethargy may also be due to her malignancy.
There is no suicidal ideation however there are thoughts of dying. She feels that she is a burden to her husband and she is using so much of their savings on medical bills. She also feels there is no reason to go on living as she will soon die because of her cancer.
Madam SMA was born in Rengit. Her developmental milestones were normal. She had formal education up till primary six. He was an average student but was unable to continue with her education as she is fourth child out of nine siblings. She had to sacrifice her education to provide for her family by working odd jobs in the kampong and help take care of her younger siblings. She learnt her tailoring skills from her neighbour. She had a lot of friends at that time from school and from the kampong and interacted well with the people around her.
She came to Batu Pahat at the age of 18 for work as most of her siblings are in Batu Pahat. She got married at the age of 22 and it was a love marriage. She is staying with her husband and 4 children in a single storey wooden kampong house. Her family and close relatives are being very supportive to her illness although she tries to avoid them. She does not smoke any cigarettes or drinks alcohol or used other illicit drugs.
Past Medical and Surgical History
There were no known medical illnesses such as diabetes mellitus or hypertension. There is no history of any allergies. The only surgery she has had was an emergency lower segment caesarean section (LSCS) during her first pregnancy 17 years ago due to fetal distress. The surgery was uneventful.
Past Obstetrics & Gynaecological History
Madam SMA has 4 children. Other than her first child that was delivered via an emergency LSCS in 1992, her 3 other children were delivered via spontaneous vaginal deliveries in 1996, 1999 and the last child birth was a year ago. All the children were breast-fed for 2 years and are currently alive and well. She used oral contraceptive pills since her first child birth 17 years ago and stopped when she wants to be pregnant. Her last Pap smear was done a year ago and the result was normal. Madam SMA attained menarche at the age of 14. She has a regular 28 days cycle that usually lasts for 7 days with moderate amount of blood flow. There was no dysmenorrhea or blood clot.
Both her parents are alive and well. Her father is 80 years old and her mother is 75 years old and they both lived in a kampong house in Rengit. She has nine siblings and all of them are alive and well. She has no family history of cancers. There is no family history of any psychiatric illnesses.
Madam SMA was a very outgoing and friendly person. She enjoyed tailoring and chatting with her clients in the kampong. She would also go out often with her husband and children on family trips to visit her other siblings and parents in Rengit. She also had a good relationship with her family.
3) FINDINGS ON CLINICAL EXAMINATION
Mental State Examination
General Appearance and Behaviour
Madam SMA is a 41-year-old Malay lady who is appears lethargic, neatly dressed in hospital attire and well-kempt. She was cooperative during the interview. She was staring at the ceiling most of the time during the interview but would occasionally make eye contact when answering a question.
Madam SMA spoke in Malay. Her speech is slow, soft and monotonous. It was coherent and relevant.
Mood and affect
She rates her mood as 4 out of 10, (1 being the profoundly sad and 10 being very happy); her affect was depressed. There is no suicidal ideation.
Thought content, Thinking & perception
She does not have any delusion or hallucinations.
She is oriented to time, place and person.
There was no memory impairment. She was able to say what she ate for breakfast indicating good recent memory. Her remote memory was also good in that she was able to say where she was born and the primary school she went to. The answers were verified by her husband. Immediate memory could not be tested as she refused to attempt to remember the three items given.
Intelligence and Abstraction
She knows who the Prime Minister of Malaysia is. She can tell the similarities of an apple and an orange.
Attention & concentration
Serial-7 test is performed. Initially, she wanted to give up at 93, but she was able to finish it correctly after a lot of motivation.
She has good judgment. She will call the fire brigade if she sees a building on fire.
She has poor insight. She knows that she is depressed but she thinks it is normal because she has cancer and it is not a problem to her and does not need treatment.
On general examination, Madam SMA was lying supine on the bed. She was alert and comfortable. She was of moderate built and well nourished. There was mild conjunctival pallor but no scleral jaundice, cyanosis or limb oedema. Oral hygiene and hydration were good.
Blood pressure: 108/70mmHg
Pulse rate: 86 beats per minute, regular in rhythm, normal volume and equal on both sides. Respiratory rate: 18 breaths per minute.
Examination of the Chest
On inspection, there was skin dimpling and peau d' orange appearance on the upper outer quadrant of the left breast. There was no erythema, ulcers or dilated veins noticed on the skin of the left breast. There was also left nipple retraction compared to the right side when she tensed her pectoralis muscles. The breasts was asymmetrical in size and shape; the left breast was appeared larger compared to the right breast and the distance between the nipples and the midline were not equal on both sides.
On palpation of the left breast, a hard lump was felt. The size was 20cm by 13cm in diameter, located in the upper outer quadrant. The margin and surface of the lump was irregular. The lump was fixed to the overlying skin and the underlying muscles. It was not warm or tender. The lump did not fluctuate or transilluminate. There was no discharge from the left nipple. Examination of the right breast was normal.
On examination of the axillary lymph nodes, 2 lymph nodes with the size of 1cm by 1 cm were palpable in the pectoral group of the left axillary lymph nodes. It was firm in consistency and non-mobile. It was non- tender. Other groups of axillary lymph nodes were not palpable. Cervical lymph nodes, supraclavicular and infraclavicular lymph nodes were not palpable.
Respiratory system examination
She did not appear to be in respiratory distress. Trachea was central. Chest expansion was normal and equal on both sides. Tactile fremitus was normal and equal on both sides. The chest wall was resonant on percussion. On auscultation, vesicular breath sounds were heard and equal. There were no added sounds.
4) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONING
Axis I (Clinical disorders):
Major depressive disorder of moderate severity
Madam SMA has been having low mood for the past 1 month. She fulfills the criteria of major depressive disorder by having low mood as well as having symptoms of loss of concentration, excessive guilt, feelings of worthlessness, social withdrawal, psychomotor retardation and loss of interest in pleasurable activities. Although there are no suicidal thoughts, she feels hopeless and pessimistic about the future and feels that death would be a release of burden from her family. She also had loss of appetite, loss of weight, insomnia and lethargy. However these symptoms may also partly be due to the malignancy. She also had impairment of social and occupational functioning as she does not want to be around her friends and family and often pushed her children away. She actually could still do some tailoring however she feels tired all the time however this fatigue may be due to her malignancy.
Adjustment disorder is defined in DSM-IV as the development of emotional or behavioural symptoms in response to an identifiable stressor that occurs within three months of the onset of the stressor. The possible stressor present in Madam SMA is the unexpected diagnosis of malignancy of breast cancer in the end stage.
The maladaptation is manifested by Madam SMA by having social withdrawal and impaired interpersonal functioning. She also had occupational functioning. Depressed mood could also be present in adjustment disorder as she also had hopeless and feeling depressed.
However, most of her other symptoms of low mood, anhedonia, insomnia, weight loss, loss of appetite, feelings of worthlessness and hopelessness, psychomotor retardation points to the criteria of Madam SMA having major depression disorder.
5) IDENTIFY AND PRIORITISE THE PROBLEMS
1. Advanced left breast carcinoma
She was diagnosed with left breast carcinoma with metastasis to the bone (Stage 4:T4N2M1). She had completed radiotherapy to her left humerus. This current admission, she was admitted for her first cycle of chemotherapy. In total, she is require to complete six cycles of chemotherapy of 5-Fluorouracil, Epirubicin and Cyclophosphamide. She should also be explained about the common side effects such as higher risk of infection as patient will be immunocompromised thus patient should be aware of the symptoms of infections and seek early treatment. Alopecia, myelosuppression, fatigue, changing urine colour, mucositis, nausea and vomiting are also some side effects that may occur. She should be advised to have frequent hand washing and to avoid close contact with people are sick. Her treatment is only palliative chemotherapy for the moment. She may be indicated for surgery if the mass in her left breast became infected, or became fungated.
2. Symptoms of major depressive disorder
She has symptoms of low mood for the past one month associated with anhedonia. She also had feelings of hopelessness and worthlessness. She feels that she is a burden to her family and there is no future for her. With also excessive feelings of guilt, loss of weight and appetite, social withdrawal, she had impairment of social and occupational functioning. She will benefit from a psychiatric referral and may require pharmalogical and non-pharmalogical intervention.
3. Financial difficulty
She has financial difficulty as she had stopped tailoring which helps contribute to the family's income. Her husband's income is also affected as he is a lorry driver, and he had made lesser trips because he has to take care of her when she goes for her treatment. Their savings are mostly used up for medical bills and they have 4 young children to provide for. She can be referred to social welfare for some further assistance.
4. Relationship with family and friends
With advanced malignancy, it's important that she have the support from her family and friends to cope with the disease. Her family and friends can show support and encourage her by telling her how much they have enjoyed her care and her friendship with them throughout these years and how they would like to spend what little time she has left meaningfully with them. This would show her that there is worth in continuing to live on. However, she had withdrawn herself from her siblings and friends. She also tries to push her children away when they want to be with her.
6) PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTS
1) Full Blood Count
Justification: Full Blood Count needs to be done to evaluate the hemoglobin level and white cell count before chemotherapy was given. Full blood count will indicate underlying infection and anemia. If there is presence of neutropenia, she cannot proceed with chemotherapy. This is because one of chemotherapy side effect is neutropenia. If she is neutropenic, and given chemotherapy, she may develop febrile neutropenia which is an oncologic emergency where patient is unable to fight infection and may require antibiotics and this is a life-threatening event. It is also important to serve as a baseline investigation for haemoglobin level, total white count and platelet count for surveillance of the myelosuppression during the course of chemotherapy.
White cell count 6.18 x109/L
Red blood count 4.72 x 1012/L
Platelet 291 x 109/L
Interpretation: Full blood count revealed no abnormality. White blood cell count was within normal range indicating the absence of infection or inflammation. She was not anemic as shown by the hemoglobin level of 139 g/L. She may proceed with chemotherapy.
2) Liver function test
Justification: Hepatic biochemical abnormalities can be detected especially with elevated liver enzymes as a result of hepatic metastasis from breast cancer. Serum albumin is used not only for an indicator of nutritional status but also found to be significant predictors of survival for those with pathological fracture secondary to bone metastasis. The liver function test is important to serve as a baseline before chemotherapy is started.
Results: Total Protein (g/L) 85 (Raised) (60-83)
Albumin (g/L) 46 (35-48)
Globulin (g/L) 39 (Raised) (28-36)
Total Bilirubin 0.7 mg/100 ml (0.2-1.4)
Direct Bilirubin 0.1 mg/100 ml
Indirect Bilirubin 0.6 mg/100 ml
Alkaline Phosphatase (u/L) 121 U/l (Raised) (36-92)
Alanine Transaminases (u/L) 15 U/l (<40)
Gamma-GT 25 U/l (1-53)
Interpretation: Total protein with raised serum globulin can be due the underlying inflammatory process which is caused by the breast carcinoma. Raised alkaline phosphatase with no other raised liver enzymes signifies that there is increased osteoblastic activity caused by the recent pathological fracture secondary to bone metastasis.
3) BUSE / Creatinine
Justification: To detect any electrolytes imbalance and prompt intervention can be given to correct the derangement before starting chemotherapy. It serves to assess the renal function and rule out possibility of renal impairment and thus the accumulation of kidney-excretion chemotherapy agents. It is also useful to determine baseline status for further monitoring during the course of chemotherapy.
Result: Urea : 3.7 mmol/L
Sodium : 138 mmol/L
Potassium : 4.0 mmol/L
Creatinine : 74 mmol/L
Interpretation: There was no electrolyte imbalance or renal impairement.
4) Ultrasound of the breasts (September 09)
Justification: While mammography is useful for identifying early-stage breast cancer, it may not be able to detect small cancers in a dense breast or in young women. As Madam SMA is in her 41 years old, ultrasound of the breast is more frequently used in young women and women in their forties as it is more superior to the mammogram in detecting ductal carcinoma in-situ and small invasive carcinoma.
Result: Large irregular heterogenous solid mass seen at the 2 o'clock position of the left breast measuring 3.6 cm x 2.5 cm x 4.0 cm. There is increased vascularity on Doppler examination. Multiple small irregular heterogenous lesions of various sizes measuring 0.5 cm to 2.0 cm were seen adjacent to the large solid mass and showed similar appearance. Two enlarged left axillary lymph nodes measuring 0.9cm and 1.1 cm respectively seen with loss of central fatty hilum and increased vascularity on Doppler. There is no obvious focal lesion seen in the right breast or right axillay lymph nodes. But there are multiple tubular anechoic structures seen radiating from the right nipple in keeping with dilated ducts.
Interpretation: There is a large left breast mass at 2 o'clock position with adjacent multiple breast masses suspicious of malignancy with metastasis of the left axillary lymph nodes. Dilated ducts as shown in the right breast are likely to be the lactating ducts of the breast.
5) Trucut Biopsy (September 2009)
Justification: Trucut biopsy is done to obtain a small cylinder of breast tissue sample for accurate histopathological examination to determine whether it is malignant or benign.
Interpretation: Histopathological examination of trucut biopsy showed invasive breast carcinoma.
6) Ultrasound of the hepatobiliary system (September 2009)
Justification: It is a quick and non-invasive screening for presence of focal lesion of liver parenchymal secondary to liver metastasis.
Result: Liver is normal in size (11 cm) with normal parenchymal echogenicity and smooth outline. There is no focal parenchymal lesion or biliary dilatation. Gall bladder is well-distended with normal wall thickness and no stone seen. Normal common biliary duct and portal vein caliber. Spleen is normal in size (8.3cm). Pancreas is normal. Both kidneys are normal in size with normal parenchyma (right kidney 9.8 cm and left kidney 9.2 cm) and there is no stone or hydroneprosis seen. Urinary bladder is well-distended with smooth regular outline.
Interpretation: There is no evidence of liver metastasis.
7) Plain radiograph of the left humerus with anteroposterior view and lateral view
Justification: To help establishing the diagnosis and determine the type of fracture, it location and the bone quality.
Result: Cracked spiral fracture of the proximal one third of the left humerus. Osteolytic changes are seen on the shaft of the left humerus with periosteal elevation.
Interpretation: Osteolytic changes are infrequent and uncommon in a premenopusal woman. The underlying pathological fracture coupled with periosteal elevation is suggestive of pathological fracture of the left proximal fracture secondary to bone metastasis from the left breast carcinoma.
8) Plain radiograph of the chest (Postero-anterior view)
Justification: Madam SMA has been having symptoms of dry cough associated with chest pain, therefore it is important to screen for lung metastasis. Pleural effusion, airway obstruction or replacement of large amount of lung parenchyma by huge tumour load may be present as especially if the patient has dyspnoea.
Result: There was multiple small opacites measuring about 0.5 cm seen at the upper and middle zones of both lung fields. However, costophrenic and cardiophrenic angles were noted indicating absence of pleural effusion. There were no osteolytic lesions seen on the ribs.
Interpretation: Presence of characteristic ‘cannon balls' lesions detected on the lung parenchymal most likely indicate lung metastasis.
*CT scan is more superior to identify pulmonary metastases when the lesions are smaller than 10 mm in diameter.
7) WORKING DIAGNOSIS AND PLAN OF MANAGEMENT ON ADMISSION
Axis I: Clinical disorder
Moderate Major depressive disorder
Axis II: Personality disorder and mental retardation
Axis III: General medical condition
Advanced left breast carcinoma with metastases to the bone and lung (T4N2M1)
Axis IV: Psychosocial and environmental problems
Financial difficulty and social isolation
Axis V: Global assessment of functioning (GAF) scale
She has moderate symptoms with moderate impairment in social functioning.
Formulation of diagnosis:
Madam SMA is a quiet and reserved lady who does not confide in others. She would keep any problems she had to herself and will not seek help from her husband or friends or her family. This may be a predisposing factor to developing depression.
The diagnosis of advanced malignancy precipitated the development of depressive symptoms. She knows that her disease is advanced and there is no cure. Her treatment is currently palliative chemotherapy.
She will have frequent hospitalization for treatment of advanced malignancy. She is also worried and feels that she is a constant burden to the family as their savings are mostly used up for medical bills. Her hopelessness and worthlessness also plays a role as perpetuation of the depressive symptoms.
My proposed plan of management:
1. Prior chemotherapy, give Intravenous Metoclopramide 10 mg and Intravenous dexamethasone 8 mg to prevent cytotoxic -induced nausea and vomiting.
2. Monitor vital signs four hourly. Review full blood count, ensure no neutropenia prior to starting chemotherapy.
3. Chemotherapy regime: Intravenous 5-Fluorourasil 912 mg, Intravenous Epirubicin 91.2 ng and Intravenous Cyclophosphamide 912 ng. (FEC regime)
(Suggested Management- Biopyschosocial approach)
Investigation: Family interview
Low dose SSRI –Fluoxetine (Prozac) 20mg daily
-to improve quality of life
Zolpidem 5mg ON – to facilitate sleep
-Patient may benefit from counseling and also discussion about end of life issues for preparation.
-To refer the patient to a palliative care unit/HOSPICE care.
-Supportive psychotherapy : problem solving skills
- Financial assistance for her and her family. Refer to Welfare department.
- She may benefit from MAKNA- National Cancer Council services
8) SUMMARY OF INPATIENT PROGRESS (INCLUDING MAJOR EVENTS, CHANGE OF DIAGNOSIS OR MANAGEMENT AND OUTCOMES)
4th of November 2009: Madam SMA was admitted on the for the first cycle of chemotherapy of the left breast carcinoma. One day prior to admission, her blood was taken for full blood count and blood urea and serum electrolyte and creatinine. Such investigations are important to determine the baseline of the parameters as well as to assess patient's ability to withstand the toxic effect of the chemotherapy. She was given intravenous metoclopramide 10 mg and intravenous dexamethasone 8 mg as pretreatment for cytotoxic-induced nausea and vomiting before starting the chemotherapy. Full blood count revealed her total white count was 6.18 x109/L which was of normal value. All the blood investigation of the patient was within normal value. She can be given chemotherapy.
5th November 2009 - She did not develop any acute complications post-chemotherapy. She was discharged home with an appointment for second cycle of chemotherapy on the 26th November and the third cycle of chemotherapy on the 10th December before she is referred to Oncology department in Hospital Sultan Ismail, Johor Bahru to decide on the further management.
She would benefit from a psychiatric referral because presence of moderate depressive symptoms. However no active management was given for her depressive symptoms.
9) DISCHARGE PLAN, COUNSELLING AND MOCK PRESCRIPTION
1) She was scheduled for a second cycle of chemotherapy with FEC regime on the 26th November and the third to be completed on the 10th December before referred to oncology department of the Hospital Sultan Ismail.
2) She should be referred for evaluation by a psychiatrist and further management for her depressive symptoms.
1) She was advised to come to the hospital if she developed fever and deteriorated rapidly after the chemotherapy as there is a risk of neutropenic sepsis.
2) She was educated on the balanced and nutritious dietary intake and advised to have a diet preferably vegetables, fruits, high-protein food to boost up her body immunity.
3) She was explained on the cytotoxic effects of the chemotherapy namely hair loss, nail colour changes, mouth ulcers, nausea and vomiting.
4) She was advised to increased water intake and reduce exposure under the sun as this may worsen the chemotherapy-induced dermopathy.
5) She should be counseled on palliative care therapy that can improve quality of life.
10) REFERRAL LETTER (MANDATORY)
Dr Karen Lai,
Hospital Batu Pahat
Hospital Batu Pahat 6th November 2010
Patient's name: Madam SMA (I/C No: 680114-01-5326)
Problem: Major Depressive Disorder of moderate severity
Thank you for seeing this 41-year-old lady who was diagnosed with advanced left breast carcinoma with metastases to the bone and lung. She presented to Hospital Batu Pahat for her first cycle of chemotherapy with 5-Fluorouracil, Epirubicin and Cyclophosphamide (FEC regime).
On physical examination, a hard, irregular lump 20cm by 13cm was located in the upper outer quadrant on palpation of the left breast with two lymph nodes with the size of 1cm by 1 cm palpable in the pectoral group of the left axillary lymph nodes. Examination of other systems was normal. Investigations showed normal full blood count and renal profile. Liver function test revealed only raised ALP which is due to increased osteoblastic activity caused by the recent pathological fracture secondary to bone metastasis. Biopsy done confirmed that it is invasive breast carcinoma. Chest radiograph revealed multiple small opacites measuring about 0.5 cm seen at the upper and middle zones of both lung fields indicating metastases deposits to the lungs.
She developed symptoms of low mood for the past 1 month. She has also been having thoughts of worthlessness, hopelessness and excessive guilt. She has also social withdrawal from her friends and family members. She has 4 children, her oldest child is 17 and the youngest is a year old. Mental state examination showed low mood with depressed affect as well as poor concentration and poor cooperation. There is no suicidal ideation. She has good family support. Kindly evaluate Madam SMA and manage her depressive symptoms as necessary. Please contact me if you require additional information of clarification. Thank you.
Dr Karen Lai
Hospital Batu Pahat
11) LEARNING ISSUES IN THE 8 IMU OUTCOMES
1) Clinical skills
How to diagnose major depression in patients with cancer?
It is important to diagnose depression in patients with cancer early because it can cause suffering, worsen quality of life, prolong hospitalization, reduces adherence to anti-cancer treatments and can lead to suicide. It can also be a psychological burden to the family of patients with cancer as well.1 Depression not only worsen the quality of life but it can also be an independent predictor of mortality.2
It is of great challenge to diagnose major depression in patients with cancer because they can present with symptoms of fatigue, lethargy, loss of appetite and weight, insomnia and decreased ability to concentrate or think. Therefore, it is difficult to decide whether these symptoms are attributable to depression or cancer.
Some studies had been done to determine depression by using several biological markers such as dexamethasone suppression test and serum cortisol by measuring the hypothalamic- pituitary- adrenal axis, Thyroid releasing hormone stimulation test by measuring the hypothalamic–pituitary–thyroid axis, serotonin-induced platelet calcium mobilization, IL-6, and omega-3 fatty acid. However, none of these markers have proved to be definitive.1The best method to diagnose major depression in patient with cancer is by clinical psychiatric interview.2 Several approaches can be used is by using the suggested criteria for diagnosing major depression in patients with cancer as listed in the table below.1
1. Dysphoric mood
2. Loss of interest or pleasure
3. Psychomotor agitation or retardation
4. Feelings of worthlessness, self-reproach or excessive or inappropriate guilt
5. Recurrent thoughts of death, suicidal ideation, wishes to be dead or suicidal attempt
Same as left
6. Diminished ability
to think or concentrate
7. Weight loss or gain or a decrease
9. Fatigue or loss
Same as left
6. Diminished ability to think or concentrate or indecisiveness
7. Not participating in medical care in spite of ability to do so, not progressing despite improving medical condition and/or in functioning at a lower level than the medical condition warrants
6. Fearfulness or depressed appearance
in face or body posture
7. Social withdrawal or decreased talkativeness
8. Brooding, self-pity or pessimism
9. Cannot be cheered up, doesn't smile, no response to good news or
Symptoms that are
clearly and fully attributable to the
condition are excluded
Symptoms are counted regardless whether or not they might be attributable to cancer
Somatic symptoms are deleted from the diagnostic criteria
If the medical condition is likely to
affect the specific symptoms (appetite/weight
change, sleep, loss of energy/fatigue,
diminished ability to think/concentrate), use the substitute symptoms
*Table adapted from Akeichi T et al General Hospital Psychiatry 31 (2009) 225–232
Based on this table, other than DSM IV criteria, a modified DSM IV which is the inclusive approach where all symptoms are considered whether or not they may be attributable to cancer. This diagnostic criteria is useful in a clinical setting when screening a cancer patient for depression in order to avoid underestimating depression. However its drawback is that it may lead to many false positive diagnoses of depression.
The second criterion was Cavanaugh criteria (the exclusive approach) in which somatic symptoms in DSM IV are deleted. Loss of energy, weight loss and insomnia are not taken into consideration when using the Cavanaugh criteria.
A third criterion is the Endicott criteria (the substitutive approach). In this approach, somatic symptoms are substituted with another symptom in cancer patients. Loss of appetite is substituted with fearfulness or depressed appearance in body or face, insomnia is substituted with social withdrawal, loss of energy is substituted with brooding, self pity or pessimism, and diminished concentration is substituted with cannot be cheered up, does not smile and no response to good news.
The authors found that the criteria proposed by Cavanaugh and Endicott had higher discrimination parameters and were therefore better markers for evaluating the severity of major depression than the inclusive criteria.1
In conclusion, these alternative criteria other than DSM IV criteria serve as a useful tool to diagnose major depression in patients with cancer.
2) Communication skills
Counseling a terminally ill patient: How to approach a patient with advanced cancer?
A patient in the advanced stage of cancer often presents with different levels of stress, emotional upsets and had to face many issues such as fear of death, interruption of life plans, change in body image and self-esteem, changed in social role and lifestyle and financial issues. Depression occurs often as a comorbidity in 15-25% of cancer patients.3
As clinicians, we must develop a treatment strategy where we encourage clear communication with the patients and the caregivers. Enabling patients and their families to ask questions that concern them promotes improved communication. Patient needs to be explained clearly about the diagnosis, the prognosis, the treatment options that are available and support that is available for the patients. We must also actively question the patient to elicit concerns about of death and the dying process or any fears that they have regarding effect of illness on family members. The physician can help patients connect with their past strengths and spiritual and religious resources when addressing their concerns, hence will improve self-esteem and coping ability and also alleviate anxiety.3
An approach that combines emotional support, flexibility, appreciation of the patient's strengths, and elements of life review with benefit patients with cancer.3 This helps the patients to develop a sense of closure and completion. When the clinician convey the potential for connection, meaning, reconciliation, and closure in the dying process help patients come to terms with impending death much easier.3
Patients need to be counsel about sadness and grief as it is a normal reaction to the diagnosis of cancer, however it is important to distinguish between normal levels of sadness and depression. They should prepare that reactions of sadness and grief can be experienced at any time throughout diagnosis, treatment, and survival of cancer. They should be counseled on how to recognize and educate upon the symptoms of depression such as disbelief, denial, or despair, difficulty sleeping, loss of appetite, anxiety, and a preoccupation with worries about the future. These symptoms and fears usually lessen when the person adjusts to the diagnosis. Signs to educate the patient and the caregivers on how to recognize the person has adjusted to the diagnosis are when the person can maintain active involvement in daily life activities, and an ability to continue functioning as spouse, parent, employee, or other roles by incorporating treatment into his or her schedule. If the family of a patient diagnosed with cancer is able to express feelings openly and solve problems effectively, both the patient and family members have less depression. 3 If depressive symptoms continue to persists, a psychiatric referral will be beneficial to the patients and their caregivers. Major depression can be treated. Psychiatry interventions that patients may benefit are such as pharmacological such as anti-depressants and non-pharmacological methods such as supportive therapy, problem solving and coping skills and cognitive behavioural therapy. Patients with advanced cancer will need good support from the family members and has proven to improve quality of life. Cancer support group is helpful as well.3
3) Application of basic science in the practice of medicine
Is there a role for antidepressants for this patient?
The principles of treatment with antidepressant medication in cancer patients should be the same as of any other patient with depression. However, we must consider that antidepressants are only prescribed for a minority of terminally ill patients. This is because majority of the patients are often in a very advanced stage of cancer and there is insufficient time for any therapeutic effect if medication is started.5
Selective serotonin reuptake inhibitors (SSRI: fluoxetine, paroxetine, and sertraline) are often the first-line for treatment of depression in terminally ill patients when immediate onset of action is not required. The onset of action is usually within 2-4 weeks. In general, paroxetine and sertraline are better tolerated compared to fluoxetine by terminally ill patients because they have fewer active metabolites hence fewer side effects.4 Fluoxetine has a longer half life therefore it is not as well tolerated compared to sertraline or paroxetine.4
Tricyclic antidepressants are also commonly prescribed to treat patients with cancer. One of the side effects of tricyclic antidepressants is anticholinergic side effects such as dry mouth and constipation which is commonly present in patients with advanced cancer. However beneficial side effect from tricyclic antidepressants is weight gain which is an advantage for patients with cancer and the sedating effect is useful when administered at night.5
In conclusion, my patient Madam SMA will benefit from anti-depressants treatment especially with SSRIs. It will improve her quality of life. However, the management of major depression in patients with cancer has to enclose an approach that combines supportive psychotherapy, patient and family education, and antidepressants.
4) Critical thinking and research
SSRI such as fluoxetine is frequently prescribed for patients with advanced cancer. Would fluoxetine versus placebo in advanced patients showed to have a better outcome in treatment?
A double blinded study6 was done on 163 patients with advanced cancer with expected survival between 3-24 months to determine whether fluoxetine versus placebo, improves overall quality of life in advanced cancer patients with symptoms of depression. Patients were screened for minimal depressive symptoms and assessed every 3 to 6 weeks for quality of life and depressive symptoms. The results showed that the use of fluoxetine was well tolerated, overall quality of life was improved, and depressive symptoms were reduced especially in patients that showed higher levels of depressive symptoms.
5) Family and community issues in health care
a) Role of caregiver and family in providing support: What can they do?
When patients with advanced cancer faced the challenges of the disease, they often develop depression. The family mainly the caregivers and friends of the patients often play an important role in providing support to the patients. A study done on how social support impacts quality of life in patients with breast cancer, and the results were that social support help in adjustment and coping with breast cancer and also to impact positively on the survivor's health.7
Patients with cancer often develops major depression and may not recognized it and attribute their symptoms due to the cancer, or they may be embarrassed to talk about it or even feel too hopeless to address the issue. Therefore as family, caregivers and friends of patients with cancer, it's important to educate themselves of the signs and symptoms of depression. When they have understood the disease and how to recognize it in patients with cancer, they are able to provide support and perhaps bring the patient or advised the patient to seek medical help.
One method that can be used by caregivers, family and friends is by creating a wellness guide.8 They can ask questions to help them understand how the depression is affecting them. Questions such as:
-What are the typical signs and symptoms of depression in your family member or friend?
-What behaviors or language do you observe when depression is worse?
-What behaviors or language do you observe when he or she is doing well?
-What circumstances trigger episodes of more severe depression?
-What activities are most helpful when depression worsens?
Their answers can provide a guide for understanding how well he or she as a patient with cancer is doing and coping with the disease.
As caregivers and family and friends of patients with cancer, they can provide support with several ways. They can let the patient know that they are willing to listen, to give positive reinforcement of their positive qualities, encourage consistent disease management, and help create a low-stress environment, offer help in household chores or certain tasks and make plans together for enjoyable activities such as walks or movies. They also need to be educated on recognizing suicide risk and never let the patient be alone and should seek help immediately.8
6) Professionalism, ethics and personal development
There was a delay in diagnosis and treatment for Madam SMA. What can be done to have prevented this event? Is there any medicolegal implications in this case?
It is often a litigation when there is a delay in diagnosis due to a physician inability to make a diagnosis. In the United States, delay in diagnosis of breast cancer is one of the most common clinical scenarios of malpractice.9 It is known that delay between onset of symptoms and initiation of treatment for breast cancer results in a more advanced stage of presentation associated with poorer survival.9 A diagnosis of breast cancer is often delayed in pregnancy or during lactation because of normal physiologic breast changes and physical examination is often focused on the abdomen and pelvis. It is often a low risk of suspicion as patients are generally younger in age.10
If the breast mass is found during pregnancy or during lactation, investigations such as a breast ultrasound should be done.11 A breast ultrasound can identify whether it is a solid, cystic lesions or a galactocele. A mammogram is not a useful tool for a woman who is lactating or a young patient (age < 35). In the young female, the breasts are very dense and it is difficult to appreciate any lesions. In the lactating breast, it is even more difficult to interpret as there is a greater increase in parenchymal density, with more nodular and rope-like characteristics which is due to ductal distention with milk.11 Fine needle aspiration can be offered if the mass is a cyst or a galactocele to confirm the diagnosis. If the mass is a solid, a biopsy is indicated. Stereotactic guidance for fine-needle aspiration or large-core breast biopsy can be used successfully in the lactating woman. To minimize creation of a milk fistula, the affected breast should be pumped just prior to the procedure. Biopsy is also indicated if the mass is palpable but the ultrasound is negative. If the abnormality is found to be malignant, then a bilateral mammogram is done, the purpose of which is to explore whether there are other suspicious lesions.
In conclusion, a breast mass found during pregnancy or during lactation should be evaluated as aggressively as to other breast mass found in a non-pregnant woman. Perhaps diagnostic delay can be reduced by providing more efficient training programs and programs targeted specifically at each age category will be beneficial to clinicians.
1. Akechi T, Ietsugu T, Sukigara M, Okamura H, Nakano T, Akizuki N, et al, Symptom indicator of severity of depression in cancer patients: a comparison of the DSM-IV criteria with alternative diagnostic criteria. General Hospital Psychiatry 2009; 31: 225–232
2. Guo Y, Musselman DL, Manatunga AK, Gilles N, Lawson K, Porter MF et al The diagnosis of Major Depression in Patients with Cancer: A comparative approach. Psychosomatics 2006; 47:376–384
3. National Cancer Institute. Depression [Online] 2009 Apr 22 [cited 2010 Jan 17]; Available from http://www.cancer.gov/cancertopics/pdq/supportivecare/depression/Patient/page2
4. Block SD. Assessing and Managing Depression in the Terminally Ill Patient. Annals of Internal Medicine 2000; 132 (3): 209-218
5. Williams ML. Difficulties in diagnosing and treating depression in the terminally ill cancer patient. Postgrad Med J 2000; 76:555–558
6. Fisch MK, Loehrer PJ, Kristeller J, Passik S, Jung SH, Shen JZ et al. Fluoxetine Versus Placebo in Advanced Cancer Outpatients: A Double-Blinded Trial of the Hoosier Oncology Group. Journal of Clinical Oncology 2003; 21(10):1937-1943
7. Yoo, GJ, Aviv C, Levine EG. Social support and breast cancer survivorship. [Online] 2004 Aug 14 [cited 2010 Jan 17] Available from: http://www.allacademic.com/meta/p108817_index.html
8. Mayo clinic.com Depression: Supporting a family member or friend with depression [Online] 2008 May 30 [cited 2010 Jan 17]; Available from: http://www.mayoclinic.com/health/depression/MH00016/NSECTIONGROUP=2
9. Tartter PI, Pace D, Frost M, Bernstein JL. Delay in diagnosis of breast cancer. Annals of Surgery 1999; 229 (1): 91-96
10. Nettleton J, Long J, Kuban D, Wu R, Shaeffer J, El-Mahdi A. Breast cancer during pregnancy: Quantifying the risk of treatment delay. Obstetrics and Gynecology 1996; 87(3): 414-418
Camillio P. Can a lactating woman have a mammogram? Medscape. [Online] 2003 Feb 25 [cited 2010 Jan 21] Available from: http://www.medscape.com/viewarticle/449395