Practice dilemma - Patient convinced she has cancer

A patient thinks she has cancer, but the GP is confident it is depression. Should the GP refer her?

THE DILEMMA

Mary is a very anxious patient who has recently developed headaches.

I believe she has moderate depression, but she has asked me whether there is any possibility of a brain tumour. I have examined her and tried to reassure her, but I am concerned that she will refuse antidepressants if I am fully truthful. I would like to say that there is nothing to suggest a sinister cause but, although it is very unlikely, there is always a slight risk. However I feel she needs a unequivocal answer.

A GP'S VIEW

Dr Louise Warburton is a GP in Ironbridge, Shropshire

Patients like Mary are very common and they vary greatly in the severity of their neurosis. In severe cases it can be impossible to shake their assumption that they have a serious problem, such as cancer. As their GP, it is your job to examine them and gently reassure them that nothing is wrong.

Obsessional neurosis about cancer is part of depression.

To refer her for a neurology assessment is the wrong thing to do in the initial stages - it will just reinforce her worries. She needs to be reassured and sent away to think about what you have said.

With early referral she might see a neurologist, have a CT scan, and be relieved for a short time, only to find something else to worry about.

It would be possible to refer her many times per year if you allowed her to manipulate you into this.

To offer her antidepressants would also be the wrong thing initially.

In my experience, getting the patient to admit that they are depressed is often the end-point of months or even years of careful negotiation on your part. Only when she has admitted that she has a mental problem will she be willing to accept any treatment.

Although patients like Mary are classic 'heartsink' patients, I enjoy caring for such people. They present a challenge and it is possible to help them to come to terms with their anxiety. It does require a lot of time and energy, but it is very rewarding and allows us to use our skills as clinicians, rather than as NHS accountants.

A PATIENT'S VIEW

Ailsa Donnelly, Patient Partnership Group

If you tell Mary that, in your opinion, the chances of her headaches being due to a brain tumour are extremely low and that the problem is more likely to be moderate depression, I do not see why she should then refuse antidepressants.

However, it would certainly be both positive and helpful to talk through Mary's fears and try to establish why she is so frightened of cancer - is there a family history, or does she know someone who has recently suffered a brain tumour, for example?

Allowing her to air her fears, taking them seriously and dealing with them with reassurance, sympathy and sensitivity might help to allay them.

If, as a GP, you feel there is 'a slight risk' and that it is not possible to give an unequivocal answer, then you should treat Mary on two fronts, both referring her for a second opinion and simultaneously prescribing antidepressants.

If the latter are going to work they will presumably take effect before her hospital appointment, which she can then cancel. She will, however, be reassured that her problems and fears are being taken seriously and this is absolutely essential.

Alternatively, you could say that, while it is not possible to say categorically that her headaches are not caused by cancer, you can reassure Mary that there is nothing to suggest cancer, prescribe the antidepressants and arrange a follow-up appointment with a promise of referral if she is not better.

Mary's fears are almost certainly contributing to her physical symptoms of headache and she therefore needs treatment. This should be by acknowledgement, understanding and reassurance.

A MEDICO-LEGAL VIEW

Dr Richard Stacey, medicolegal adviser at MPS

Anxiety and headaches are two very common presenting symptoms in general practice and, in the majority of cases, there is no sinister cause for these symptoms.

Conversely, the delay in diagnosis of life-threatening causes of headaches is a common pitfall, which might give rise to a complaint, and you should therefore have a high index of suspicion of such pathologies.

In light of the fact that Mary has specifically asked you about the possibility of a brain tumour, you should respond to her request, based on the information available to you and in a way that she will understand.

According to your description of the case, there are no obvious symptoms that would prompt a referral. Of course, you will not be able to give Mary an unequivocal answer, but it would be helpful to explore her concerns - she might, for example, have had a friend or a relative with a brain tumour.

You could also discuss with her the merits of obtaining an opinion from a consultant colleague.

It is understandable that you are concerned that Mary may decline antidepressant treatment if she is anxious about the possibility of a brain tumour, but it is possible that worrying about a tumour might be one of the sources of her anxiety.

The advantages and disadvantages of antidepressant therapy can always be revisited once you have reached a shared agreement as to whether the headaches warrant further investigation.

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