Monday, May 26, 2008

Denying the Obvious: How to Approach Patients
Who Delay Medical Care for Advanced Breast Cancer

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By Winifred G. Teuteberg, MD
Vol 8, No. 2 - March 2008
(Original PDF)

MM is a 77-year-old woman who presented to the emergency department with flu-like symptoms. On exam she had a large palpable mass in her left breast. A CT scan revealed a 10cm left breast mass and liver and lung metastases. After admission to the hospital, the breast mass was biopsied. The consulting oncologist met with MM and told her that she most certainly had metastatic breast cancer, although the biopsy results were not yet available. The primary service asked palliative care to see MM because of her advanced disease. There was also concern that she did not understand her diagnosis.

I came into the patient’s room and introduced myself, saying, “I see many of the breast cancer patients on this floor.” The patient stopped me, saying, “I don’t have cancer.” I apologized and asked if I might sit down and talk with her. I asked her to explain what she understood of her illness. She said she had fallen several months before and bruised her left breast. It had been sore ever since but she was otherwise fine until she developed “flu” and came to the emergency department. She understood that a scan showed “something in my liver,” but believed that without the biopsy she did not have cancer.
I explained that her doctors were concerned she had cancer. I then asked her what she was most worried about. She told me that her husband died from lung cancer the year before after a two-year battle with the disease. She said, “I’m afraid I’ll suffer the way he did with chemotherapy and radiation and die anyway.” I counseled her that some patients with metastatic breast cancer choose to focus on comfort, rather than pursue aggressive therapies that may not help them achieve more quality time. She was relieved to hear that this was possible. She was discharged with a plan to discuss treatment options with her oncologist but was also considering referral to hospice.
A large part of my clinical practice involves providing inpatient palliative care consults to breast cancer patients. During my three years of practice in this setting, I frequently encounter women presenting with palpable, often fungating, breast masses. In nearly all of these cases patients sought medical attention for a symptom not obviously related to the mass or at the request of a concerned friend or family member. Even after being told their diagnosis, patients often did not accept it and continued to believe their symptoms were related to something else. They can continue in this belief for months and sometimes years. When other health care providers encounter these patients, they are struck by the magnitude of their denial.
Upon review of the literature, denial of obvious breast cancer and delay in presentation for medical care is quite common. Approximately one third of patients present for evaluation more than 12 weeks after developing symptoms and about 5% present more than a year after noticeable symptoms. Most of these patients present with locally advanced or metastatic disease. Studies identify several reasons for this delay, most of them related to the patients’ initial psychological response to their symptoms. Patients who delayed presentation were more likely to have significant fear of cancer itself and/or therapies for cancer including disfiguring surgery. Many patients noticed a lump but believed that the lump would go away or attributed it to another cause. Others did not know that breast cancer is a potentially curable illness and fatalistically did not seek treatment because they believed they were going to die no matter what they did. In several studies patients reported that they knew the symptom was serious, but were too busy caring for others such as young children or sick family members to take time to seek medical advice.
Interestingly, although some studies found a small increased incidence of psychiatric illness in patients who delayed presentation, studies found no significant differences in psychological well-being between patients with early versus late presentation.
When caring for such patients, it is important to realize that their reasons for delaying presentation or even acknowledging their illness are significant for them. Rather than initially attempting to change their beliefs and force them to accept their diagnosis, it is best to first explore their fears and identify ways to help allay these fears. In the case of MM, her fear was that she would suffer the way her husband did and die anyway. Although I was not able to cure her cancer, I was able to provide comfort by offering her a way to avoid the suffering that her husband endured.
1. Phelan M, Dobbs J, David AS. ‘I thought it would go away’: patient denial in breast cancer. J R Soc Med 1992;85;206-207. Full PDF
2. Mohamed IE, Williams KS, Tamburrino MB, et al. Understanding locally advanced breast cancer: What influences a woman’s decision to delay treatment? Preventive Medicine 2005;41:399-405. 10.1016/j.ypmed.2004.12.012 [doi]
3. Burgess CC, Potts HWW, Hamed H, et al. Why do older women delay presentation with breast cancer symptoms? Psycho-Oncology 2006;15:962-968. 10.1002/pon.1030 [doi]

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Who Delay Medical Care for Advanced Breast Cancer”