Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Psycho-oncology: Psychiatric Co-morbidities and Complications of Cancer and Cancer Treatment


Key Points

  • By exploring the patient's capacity to consider choices, psychiatrists convey respect and enhance the patient's conviction of influence on the world. The sense of purpose adds value to life regardless of time frame. Additional psychosocial interventions combine education, relaxation skills, and social support.

  • So that treatable psychiatric syndromes do not interfere with quality cancer care, psychiatrists diagnose and plan specific treatment. They also may use stimulants for fatigue, tranquilizers for nausea, and antidepressants for hot flushes.

  • In patients with cancer, major depressive disorder is associated with poor quality of life, worse adherence to treatment, longer hospital stays, greater desire for death, and an increased suicide and mortality rate.

  • Delirium in patients with cancer results from infection, opiates, recent surgery, hyponatremia, hypercalcemia, brain tumors, and leptomeningeal disease. Specific causes of delirium may be associated with specific cancers, hyperviscosity syndrome, Cushing's syndrome, paraneoplastic encephalomyelitis, and limbic encephalitis.

  • Neuropsychiatric cancer-drug-induced side effects are most associated with biologicals, steroids, and interferon. White matter injury from chemotherapy and central nervous system radiation can cause learning difficulties and behavioral syndromes in survivors.

The Role of Psychiatry in the Care of Cancer Patients

The seriousness of the diagnosis of cancer challenges the capacity to survive, to set a course in life, and to fulfill hopes and dreams. Over the twentieth century, even as cancer treatments improved and some patients were cured, psychiatrists in the tradition of humane psychiatry used their skills to stand by patients who were overwhelmed, to help them to speak in their own voices, to make complex treatment choices, and to shape the rest of their life or the end of life. Psychiatrists have offered expert diagnosis and management of co-morbid psychiatric syndromes and collaborated with oncologists so that treatable psychiatric illness does not stand in the way of technical oncological care. Specific cancer-related or cancer-treatment-related neuropsychiatric syndromes ( Boxes 56-1 to 56-4 ) can be recognized and treated. Psychiatrists can help patients to cope with physical symptoms, developmental losses, changes in relationships, and the effects of cancer on families.

Box 56-1
Neuropsychiatric Side Effects of Cancer Drugs

Hormones

Anti-estrogens

  • Tamoxifen, toremifene: hot flushes, insomnia, mood disturbance; at high doses tamoxifen can cause confusion

  • Anastrazole (Arimidex), letrozole (Femara), exemestane (Aromacin): hot flushes, fatigue, mood swings, and irritability; cognitive effects are not known

  • Raloxifene (Evista): no cognitive side effects noted

  • Leuprolide (Lupron), goserelin (Zoladex): hot flushes, fatigue, and mood disturbance

Androgen Blockade

  • Leuprolide (Lupron), goserelin (Zoladex): hot flushes, fatigue, and mood disturbance

  • Flutamide (Eulexin), bicalutamide (Casodex), nilutamide (Nilandron): as above

Glucocorticoids

  • Dose-related, variable psychiatric side effects including insomnia, hyperactivity, hyperphagia, depression, hypomania, irritability, and psychosis

  • Treated by ad hoc antipsychotics easily with cancer patients

  • Other drugs with benefit: lithium, valproate, lamotrigine, and mifepristone

  • Dexamethasone (Decadron) 9 mg equals 60 mg of prednisone; psychiatric side effects are associated with this dose level

  • Steroids used as part of an antiemetic treatment with chemotherapy infusion, with lymphoma protocols as high as prednisone 100 mg for 5 days, with nervous system radiation treatment to reduce swelling, with taxanes to reduce side effects

IV, Intravenous; MAO, monoamine oxidase; SIADH, syndrome of inappropriate antidiuretic hormone.

Box 56-2
Biologicals

Interferon-alpha

  • Depression, cognitive impairment, hypomania, psychosis, fatigue, and malaise

  • Responsive to antidepressants, hypnotics, antipsychotics, stimulants, and antianxiety agents

  • Associated with autoimmune thyroiditis that may increase or decrease thyroxine; check thyroid function

  • May inhibit metabolism of some antidepressants by P450 enzymes CYP1A2, CYP2C19, CYP2D6

  • Interferon-beta has less neurotoxicity

Interleukin-2

  • Delirium, flu-like syndrome, dose-dependent neurotoxicity, and hypothyroidism

IV, Intravenous; MAO, monoamine oxidase; SIADH, syndrome of inappropriate antidiuretic hormone; TSH, thyroid-stimulating hormone.

Box 56-3
Chemotherapy

Vincristine (Oncovin), vinblastine (Velban), vinorelbine (Navelbine)

  • Neurotoxicity is dose-related and usually reversible. Fatigue and malaise are noted. Seizure and SIADH are uncommon. Postural hypotension may be an aspect of autonomic neuropathy.

  • Less toxicity is noted with vinblastine and vinorelbine.

Procarbazine (Matulane)

  • Mild reversible delirium, depression, and encephalopathy

  • A weak MAO inhibitor

  • Antidepressant use must consider the timing of procarbazine or risk serious interactions

  • Disulfiram-like effect; avoid alcohol

Asparaginase (Elspar)

  • Depression, lethargy, and delirium with treatment

Cytarabine (ARA-cell, Alexin)

  • High-dose IV treatment (over 18 g/m 2 /course) can cause confusion, obtundation, seizures and coma, cerebellar dysfunction, and leukoencephalopathy. Older patients with multiple treatments are more susceptible. Delirium and somnolence can be seen 2–5 days into treatment. Those with renal impairment are more vulnerable.

Fludarabine (Fludara)

  • Rare somnolence, delirium, and rare progressive leukoencephalopathy

5-Fluorouracil (5-FU)

  • The primary neurotoxicity is cerebellar, but encephalopathy with headache, confusion, disorientation, lethargy, and seizures has also been seen.

  • Rare deficiency of enzyme that metabolizes dihydropyrimidine dehydrogenase (DPD) is associated with greater exposure and more toxicity.

  • Fatigue is the most common side effect.

  • Cerebellar syndrome and rarely seizure or confusion or parkinsonism may be noted.

  • High-dose IV thymidine may be an antidote for toxicity.

Capecitabine (Xeloda)

  • Related to 5-FU, but with less neurotoxicity

Methotrexate

  • Causes neurotoxicity particularly when the route is intrathecal or high-dose IV (usually over 1 g/m 2 ). The toxicity, which is usually reversible, is related to peak level and duration of exposure. Leptomeningeal disease or other conditions that break the blood–brain barrier may impair drug clearance. Prolonged exposure allows the drug to pass through the ependyma of the ventricles to cause leukoencephalopathy. The risk is greater in patients also exposed to cranial radiation. Intrathecal methotrexate may also cause seizures, motor dysfunction, chemical arachnoiditis, and coma. Serum levels are followed closely; folinic acid (leucovorin) rescue is an antidote. Alkalinization may lower the serum level.

  • There is a dose- and route-related risk of delirium.

Pemetrexed (Alimta)

  • An antifolate given with supplements of folate, intramuscular vitamin B 12 , and dexamethasone. It is associated with a 10% rate of depression and fatigue.

Gemcitabine (Gemsar)

  • Fatigue, flu-like syndrome, and a rare autonomic neuropathy

Etoposide (Eposin)

  • Postural hypotension and rare disorientation

Carmustine (BCNU)

  • Delirium, only at high dose, rare leukoencephalopathy

  • Thiotepa

  • Rare leukoencephalopathy

Ifosfamide (Ifex)

  • Transient delirium, lethargy, seizures, drunkenness, parkinsonism, and cerebellar signs that improve within days of treatment

  • Risk factors: liver and kidney impairment

  • Hyponatremia

  • Leukoencephalopathy

  • Thiamine or methylene blue may be antidotes

Cisplatin

  • Rare reversible posterior leukoencephalopathy, parietal, occipital, frontal with cortical blindness.

  • Peripheral neuropathy, poor proprioception, and rarely autonomic

  • Hypomagnesemia secondary to renal wasting

  • Vitamin E (300 mg), amifostine may limit peripheral toxicity

  • Hearing is decreased due to dose-related sensorineural hearing loss

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Related Posts