INTRODUCTION
The belief that cancer represents a threat is still prevalent in our occidental society. It is still strongly associated to a dreadful and painful end of life with an inescapable or impending death that nothing can stop. These beliefs and misconceptions may contribute to inappropriate behavior such as “cancerophobia” and denial with subsequent frequent delays in seeking medical consultation and treatment for suspected malignancy (Oster et al., Reference Oster, Vizel and Turgeon1978).
Cancerophobia or carcinophobia is a pathological thought that consists of the fear and the obsession of suffering from cancer or even being in contact with a cancer patient (Dargent & Vauterin, Reference Dargent and Vauterin1961). This morbid dread of being afflicted by cancer can lead to repeated medical consultations and paraclinic exams that will hardly reassure the patient.
From a psychoanalytic point of view, denial can be considered as “an unconscious repudiation of reality” (Salander & Windahl, Reference Salander and Windahl1999).
Nevertheless, denial might also be viewed as a pathological and ineffective defense mechanism with prevalence for cancer disclosure estimated between 4% and 47% (Vos & De Haes, Reference Vos and De Haes2007). Denial of impact and affect is, respectively, estimated to be between 8% and 70% and 18% and 42% (Vos & De Haes, Reference Vos and De Haes2007). The denial process will help the patient's mind to defend itself against painful or threatening thoughts, such as fear of cancer and all the information associated or fear of death or suffering from this illness (Rabinowitz & Peirson, Reference Rabinowitz and Peirson2006). At the beginning, denial may be considered as an important adaptive or coping function in a person facing the challenge of cancer. Nevertheless, rapidly, it may also become dysfunctional, especially if it causes delay or avoidance in seeking treatment for symptoms relevant for a true malignancy and will lead inexorably to death if not cured.
We describe the case of a patient who presented both cancerophobia and denial of an advanced ovarian cancer.
CASE REPORT
In January 2008, a 62-year-old woman was admitted to the emergency room of our cancer center for severe dyspnea and bedridden state. She had not had any relevant familial or personal previous medical history, excluding morbid obesity (110 kg, 163 cm on September 2007). Since this date, she had experienced and wittingly concealed from her husband anorexia, weakness, minor pelvic pain, and increasing size of her abdomen. She had postponed surgery because of her fear of a cancer diagnosis. Since then, she had developed cancerophobia. The CT imaging revealed huge cystic peritoneal masses and abundant ascitis. The tumor marker CA-125 was 1095 times the upper limit of normal. The level of pre-albuminemia confirmed the masked severe denutrition 0.07 g/l (normal value: 0.19–0.34). A 14-L ascitis puncture improved her breathing but without significant reduction of the abdomen volume. The cytological analysis of ascitis revealed the presence of carcinomatous cells. But the patient died of a septic shock 3 days after admittance.
DISCUSSION
Denial in oncology is a complex and multidimensional concept that depends of the instruments used to assess it and demographic variables such as age, gender, ethnic, cultural background (Vos & de Haes, Reference Vos and De Haes2007).
Even if denial could have adaptive properties (such as a normal response to serious illness) supported by empirical research (Goldbeck, Reference Goldbeck1997; Moyer & Levine, Reference Moyer and Levine1998), denial of symptoms is an example of an inappropriate coping response to the detection of cancer-related symptoms and can be related to less-known symptoms and heightened perception of threat (Ruiter et al., Reference Ruiter, de Nooijer and van Breukelen2008). Some recent studies have tended to find a link between passive cancer detection behavior (attentiveness to cancer symptoms such as unusual blood loss) and timely medical help seeking (van Osch et al., 2007). Moreover, some psychosocial determinants such as premotivational awareness factors (knowledge and awareness), female gender, and perceived advantages could play a role in passive detection behavior (van Osch et al., 2007). Some patients confronted with a cancer diagnosis can deny it due to the self-induced nature of their disease, the projections, and their own representations of the illness.
Denial is not a longitudinal and rigid process and can vary over time and course of the disease even if it is suggested that later disease stages but not type of tumor seem to be associated with higher prevalence of denial (Vos & de Haes, Reference Vos and De Haes2007).
Clinicians confronted with patients' denial about advanced cancer can have feelings of frustration, helplessness, and hopelessness. They have to grieve or overcome their medical power that appears to be useless or even irrelevant to deal with this specific situation. The unawareness of physical symptoms by the patient can create a gap of misunderstanding between him and the practitioner who found specific abnormalities in his physical examination.
The medical team cannot force the patient to accept the therapeutic project and is confronted with ethical issues such as respecting patients' autonomy and self-determination and preserve non harmful behavior (Blustein, Reference Blustein1993; Luce, Reference Luce1995).
To manage patients with cancerophobia and denial who really present with a cancer, we outline some recommendations (Garner, Reference Garner1964): First, it is important to respect an attitude that will not destroy the patient's psychological defenses by abruptly telling him the truth. Empathic and not rejecting attitudes must be prevalent in the medical care.
Allow the denial of the illness as long as it represents the patient's own solution for coping with his fear and anxiety except if it impairs the treatment. The doctor can say something like, “A tumor was found and it needs to be removed.” At this point, no more exact information needs to be given than that demanded by the patient.
Tell the truth at all times, except on rare occasions, but at a pace demanded by the patient and not based on preconceived notions of the practitioner. The doctor could say something like, “It must be obvious to you that I suspect the tumor is malignant, but there can be no absolute answer at this time before completing all the exams.”
Give encouragement even if it is bad news for the patient, and discourage thinking that findings can only bring disheartening information.
For example, if the patient tells the doctor, “I have a cancer,” he could answer, “Yes, it seems that you have this disease but I wonder why you have to see it as a hopeless condition. I have seen many patients with a similar medical condition that have recovered from cancer.”
In conclusion, cancerophobia and denial represent two psychological conditions that put the patient at high risk of not receiving early diagnosis and therefore full cancer treatment regimens or standard protocols. These patients, when it is possible for the medical team to reach them, are often seen at an advanced stage of their disease with a loss of potential benefit of efficient treatment that could not be implemented sooner.
These patients raise specific ethical and psychological issues that cannot be ignored. Therefore, the oncologist must work with the psycho-oncology team to manage these types of patients.
