Adjuvant Chemotherapy in Schizophrenic Patients with Breast Cancer

Abstract

Introduction: Anecdotal evidence suggests that schizophrenia, a thought disorder affecting ∼1% of the population worldwide, affects the clinical course of patients with unrelated medical problems. We sought to quantify this in schizophrenic patients with breast cancer who were offered adjuvant chemotherapy. Methods: The Patient Treatment File (PTF), a nationwide inpatient computer database for the Department of Veterans Affairs (VA) was used to gather information on schizophrenic patients who were later treated for breast cancer during years 1999-2005. Chart-based clinical indicators from VA Medical Centers nationwide supplemented the PTF data. A study on outcomes of breast cancer surgery using data from the VA National Surgical Quality Improvement Program (J Am Coll Surg, 2004;198:707-716) served as our control group for demographic and pre-treatment data. Results: Of the 126 patients initially identified by computer codes, 56 appeared to be appropriate candidates for adjuvant systemic therapy and were deemed evaluable by our predetermined criteria. There were 18 men (32%) and 38 women (68%). Of the 44 patients for whom living conditions were documented, 24 (55%) were in assisted living facilities (homes of family members, group homes, institutions and nursing homes), 17 (39%) were independent and 3 (7%) were homeless; 10 of the 17 (59%) independent schizophrenic patients for whom data were available had been institutionalized within 2 years prior to their breast cancer treatment. Before breast cancer treatment, 5 of the 56 (8%) had documented homicidal ideation; 17 of the 56 (28%) had documented suicidal ideation; 12 patients (21%) had previously attempted suicide. At least 10 of the 56 patients (18%) had verbally abused healthcare workers; 7 patients had physically assaulted caregivers. Fourteen of the 35 patients (40%) for whom staging data were available had TNM stages III-IV; at least 5 of these 14 had ignored obvious signs of breast cancer (mass and/or ulceration noted by patient) for 6 months to 9 years; 4 other patients with biopsy-proven cancer delayed treatment for >3 months. In the 25 patients for whom tumor size was recorded, 17 (65%) were>2 cm (mean=5.8 cm). Among the 56 patients who appeared to be candidates for adjuvant cytotoxic therapy, there were 46 for whom adequate data about this option were available; 39/46 (85%) were offered post-operative cytotoxic chemotherapy; 12 of these 39 (31%) refused or were non-compliant. Among the 56 patients who appeared to be candidates for adjuvant endocrine therapy, there were 38 for whom adequate data about this option were available; 25/38 (65%) were offered post-operative endocrine therapy; 8 of these 25 (32%) refused or were non-compliant. Conclusion: This is the initial report on the clinical course of schizophrenic patients who are eligible for adjuvant systemic therapy. Because of their thought disorder, schizophrenic patients do not understand their health problems well. Schizophrenic patients often have advanced-stage cancer at diagnosis, often delay diagnosis, and frequently display hostility to healthcare workers. Many refuse therapy and/or are non-compliant. Multimodality treatment to preserve the breast requires patient cooperation. Schizophrenic patients may be better served by radical surgery as initial therapy.