A 60-year-old woman with a history of locally advanced breast cancer comes to the office for scheduled follow-up. The patient underwent a lumpectomy followed by radiation therapy and completion of chemotherapy 6 months ago. She is currently taking an aromatase inhibitor. The patient feels that the fatigue she experienced during her chemotherapy has not improved. She has been sleeping poorly and recently left her volunteer job at the library because she is "too distracted to sit and alphabetize books." The patient had previously been meeting weekly with friends for lunch but has not replied to recent invitations. Since her last appointment 3 months ago, she has lost 3 kg (6.6 lb); otherwise, vital signs are within normal limits, there are no changes on physical examination, and laboratory and imaging studies are unremarkable. When informed of these normal results, she says, "That's good to hear, but I'm anxious that the cancer is coming back. Why else would I feel so tired all the time?" Which of the following is the most likely explanation of this patient's condition?

Question

A 60-year-old woman with a history of locally advanced breast cancer comes to the office for scheduled follow-up.  The patient underwent a lumpectomy followed by radiation therapy and completion of chemotherapy 6 months ago.  She is currently taking an aromatase inhibitor.  The patient feels that the fatigue she experienced during her chemotherapy has not improved.  She has been sleeping poorly and recently left her volunteer job at the library because she is "too distracted to sit and alphabetize books."  The patient had previously been meeting weekly with friends for lunch but has not replied to recent invitations.  Since her last appointment 3 months ago, she has lost 3 kg (6.6 lb); otherwise, vital signs are within normal limits, there are no changes on physical examination, and laboratory and imaging studies are unremarkable.  When informed of these normal results, she says, "That's good to hear, but I'm anxious that the cancer is coming back.  Why else would I feel so tired all the time?"  Which of the following is the most likely explanation of this patient's condition?

Quizplus · Accepted Answer

Although fatigue may persist after completion of chemotherapy, and anxiety about cancer recurrence is normal, this patient is showing other signs and symptoms that are concerning for major depressive disorder (MDD). She has loss of interest (eg, no longer meeting her friends for lunch), impaired concentration (eg, too distracted to alphabetize books), sleep disturbance, weight loss, and social isolation (eg, not responding to invitations) lasting >2 weeks, strongly suggestive of MDD. This should prompt assessment of other depressive symptoms (eg, feelings of worthlessness/guilt, loss of self-esteem, suicidal ideation). Recognition of major depression in medically ill patients is important because untreated depression can have a major impact on quality of life and can negatively affect treatment adherence and medical outcome. Physicians should not assume that depression is a normal reaction to a cancer diagnosis or that impairment in sleep, appetite, and energy level are due to the cancer or its treatment. Patients with cancer can be safely and effectively treated with psychotherapy and/or antidepressant medications. (Choice A) Although some of the patient's symptoms (eg, fatigue, cognitive problems) could be caused by an aromatase inhibitor, her anhedonia, poor sleep, and weight loss raise concern for MDD. Musculoskeletal symptoms (eg, arthralgia, joint stiffness, bone pain) and sexual dysfunction are the most common side effects of aromatase inhibitors. (Choice B) Depressive disorder due to another medical condition is only diagnosed when there is evidence that the mood disturbance is the direct result of another medical condition (eg, hypothyroidism, Parkinson disease). In the absence of any findings on physical examination or laboratory and imaging studies, this patient's depression is unlikely due to breast cancer recurrence or another undiagnosed medical condition. (Choice C) Illness anxiety disorder involves excessive fears of having a serious illness. It would not explain this patient's depressive symptoms, and her fear of breast cancer recurring is normal. (Choice E) This patient's symptoms are more severe than would be seen in a normal reaction and are causing significant distress and functional impairment. Further assessment and treatment are indicated. Educational objective: Diagnosing major depressive disorder in patients with cancer is difficult because somatic symptoms of depression (eg, fatigue, weight loss) may overlap with those of cancer and its treatment. If these symptoms are associated with depressed mood or loss of interest, major depressive disorder should be considered. References: Efficacy and acceptability of antidepressants on the continuum of depressive experiences in patients with cancer: systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26118318) Distinguishing depressive symptoms from similar cancer-related somatic symptoms: implications for assessment and management of major depression after breast cancer. (http://www.ncbi.nlm.nih.gov/pubmed/28973709)

A 60-Year-Old Woman with a History of Locally Advanced Breast