Coping with Comorbid Cancer and Schizophrenia:

A Case Series Analysis

Citation:

 

 

Abstract
Many individuals with schizophrenia develop cancer.  This case series examined how this comorbidity affects individuals’ self-concept, illness perception, and illness outcomes.  Coping strategies were studied, inspired by Lazarus and Folkman’s problem-focused vs. emotion-focused coping stress-appraisal framework.  Four adults diagnosed with schizophrenia and cancer participated.  Data was collected by means of individual semi-structured interviews, which were analyzed using thematic analysis.  Self-concept was either threatened or unaffected by this comorbidity. All cancer diagnoses were accepted and perceived as the more severe illness.  Illness outcomes were perceived as negative due to increased worry and fear about cancer prognosis and worsening of mental health symptoms after cancer diagnosis.  All participants utilized problem-focused and emotion-focused coping strategies.  Comorbidity was perceived as both improving and complicating coping with both schizophrenia and cancer.  Hypotheses were generated for future research, which is needed in relation to experiencing and coping with comorbid cancer and schizophrenia.

Key Words – cancer, comorbidity, coping, experience, schizophrenia

Introduction:
Schizophrenia is a serious mental illness associated with substantial complications to health and well being.  Approximately half of individuals with schizophrenia have at least one comorbid psychiatric or general medical condition, which can lead to a worse course and treatment outcome of both the schizophrenia and the comorbid illness (Leucht, Burkard, Henderson, Maj, & Sartorius, 2007).  Cancer is of particular importance in this context, since it is the second most frequent cause of mortality in people with schizophrenia (Leucht, Burkard, Henderson, Maj, & Sartorius, 2007).  Traditional research on comorbid cancer and schizophrenia has focused on incidence, prevalence and risk factors of cancer and has sometimes yielded conflicting results.  Depending on the type of cancer, cancer risk of people with schizophrenia may be the same, less than, or greater than in the general population (Tran et al., 2009).  According to Catts and colleagues, when pooled incidence rates were compared between people with schizophrenia and their first degree relatives, the incidence for cancer was not significantly increased in those with schizophrenia (Catts, Catts, O Toole, & Frost, 2008).  However, esophageal and breast cancer are significantly more prevalent in people with schizophrenia (Goldacre, Kurina, Wotton, Yeates, & Seagroatt, 2005; Barak, Levy, Achiron, & Aizenberg, 2008; Grinshpoon et al., 2005), whereas colon and skin cancer are significantly less prevalent in people with schizophrenia (Goldacre et al., 2005).  Different explanations have been proposed regarding cancer prevalence in schizophrenia, e.g., that schizophrenia includes a vulnerability towards developing cancer (Preti, 2008); that schizophrenia includes a genetic protective factor against particular types of cancer (Catts et al., 2008; Cohen, Dembling, & Schorling, 2002; Levav et al., 2007); and that schizophrenia includes a protective factor against cancer through use of antipsychotic medication (Japlensky & Lawrence, 2001).  

 Considerably less research is found on psychological aspects of comorbid cancer and schizophrenia, particularly on coping with such a comorbidity.  Inagaki and colleagues examined patients with schizophrenia in relation to their adherence to cancer treatment, demonstrating that severe psychiatric symptoms and cognitive impairments interfered with effective management of cancer (Nordenberg, Fenig, Landau, Weizman, & Weizman, 1999).  Coping with cancer (Inagaki et al., 2006; Kim, Yeom, Seo, Kim & Yoo, 2002; Kyngas et al., 2000; Link, Robbins, Mancuso, & Charlson, 2005; Park, Edmondson, Fenster, & Blank, 2008; Parle & Maguire, 1995) and coping with schizophrenia (Wonghongkul, Moore, Musil, Schneider, & Deimling, 2000; Cooke et al., 2007; Knudson & Coyle, 2002; Ritsner & Sussner, 2004; Rudnick, 2001; Strous, Ratner, Gibel, Ponizovsky, & Risner, 2005) have been studied as separately occurring illnesses, utilizing established coping frameworks, such as Lazarus and Folkman’s problem-focused and emotion-focused coping stress-appraisal approach.  This approach categorizes problem-focused coping strategies as those which address the problem, such as by weighing alternatives, determining costs and benefits of certain behaviours, and generating alternative solutions.  This method of coping is adaptive in situations where the problem can be resolved.  Emotion-focused coping strategies are those which address the distress caused by the problem, such as by avoidance, minimization, and cognitive reappraisal (Tong, Wang, & An, 2008). This type of coping is said to be more adaptive in situations where it is more feasible to regulate one’s feelings towards the problem rather than to resolve the problem.  These two types of strategies of coping can be mutually facilitative; however, they can also impede each other.

To date, there is no published research on coping of individuals with comorbid cancer and schizophrenia.  Comorbid populations may be distinct, since they have both illnesses and may have complex coping patterns that cannot be predicted from data on those with only cancer and those with only schizophrenia.  Since cancer is the second most frequent cause of mortality in people with schizophrenia (Tran et al., 2009), knowledge about the experience and coping of this comorbidly ill population can have important health care implications for illness management and psychosocial rehabilitation.  For example, psychosocial rehabilitation approaches have been utilized for those with schizophrenia (Yasrebi, Jazayeri, Pourshahbaz, & Dolatshahi, 2009), as well as those with cancer (Mikkelsen, Sondergaard, Sokolowski, Jensen, & Olesen, 2009) and have yielded positive results.  However, this research does not examine coping with such a comorbidity.  Recent research in psychosocial rehabilitation for those with serious psychiatric disabilities has integrated physical wellness components into treatment perspectives (Skrinar, Huxley, Hutchinson, Menninger, & Glew, 2005). Hence, a natural continuation of this line of research is to explore this experience of and coping with this comorbidity.

This study sought to explore experience of and coping with comorbid cancer and schizophrenia, using first person accounts.  Since this was an exploratory study, a case series and qualitative method were used to help inform future hypotheses.  This paper presents focused reports of four individuals diagnosed with comorbid cancer and schizophrenia.  Two research questions were addressed: (1) How does the comorbidity of cancer and schizophrenia impact these individuals’ experiences of: (a) themselves (self-concept); (b) their comorbid illnesses; and (c) the outcomes of their comorbid illnesses. (2) How do these individuals cope with these comorbid illnesses, particularly in relation to problem-focused and emotion-focused coping?

Methods
Participants recruited for this study met predetermined inclusion criteria: (1) a primary diagnosis of schizophrenia; (2) any cancer diagnosed after their first psychiatric admission and no earlier than five years prior to the date of the interview (to minimize recollection bias), and (3) no diagnosis of autism spectrum disorders, moderate or more severe mental retardation, or dementia (since these particularly serious cognitive impairments could confound findings).  

All psychiatrists and mental health care team staff at the participating mental health program were informed of the study and identified appropriate participants that were interested in being approached by the principal author for further information about the study.  Five individuals were deemed suitable and were approached by the principal author to explore informed consent. Of these, three agreed to participate.  One additional participant was identified at the local cancer center and agreed to participate.  All four participants provided voluntary and capable informed consent.  This study received ethics approval from the local university’s Health Sciences Research Ethics Board.

Data collection consisted of three parts: (1) collection of demographic information (including retrospective clinical chart review); (2) administration of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders for Axis One disorders (SCID-I) based the DSM-IV to determine if diagnostic criteria for schizophrenia were met (First, Spitzer, Gibbon, & Williams, 1995); and (3) our novel semi-structured qualitative interview which consisted of seven open ended questions and prompts for clarification addressing experience of, and coping with, comorbid cancer and schizophrenia; this interview was primarily phenomenological (Creswell, 2007). The retrospective clinical chart review included gathering relevant background information, such as cancer diagnosis and treatment.  Such information, along with the participants’ psychiatric diagnoses, can be found in Table One.  The questions for the semi-structured interview inquired about the illnesses effects on the participant’s self image, reflections about having two illnesses, outcomes of the illnesses, and how he or she cope with these illnesses.  Sample questions included, “How does/did having cancer and schizophrenia affect how you feel and experience yourself?”, and “How do you think dealing with your cancer affects/ed how you cope with your schizophrenia?”  Pre-determined prompts were used if the patient required more clarification about the question. The semi-structured interview guide is available electronically from the authors on request.  All data collection was conducted by the principal author, who received formal training in the administration of the SCID-1.    

Table One: Psychiatric Diagnoses, Cancer Diagnoses, and Treatments of Participants A-D

Participant	Schizophrenia Classification	Psychiatric Comorbidities	Psychiatric Treatment	Cancer Diagnoses	Cancer Treatment
A	Paranoid (in remission)	- Bipolar Disorder Type 2 (in remission) - Anxiety Disorder NOS (Not Otherwise Specified – mixed anxiety symptoms)	Antipsychotic Medication	Breast cancer Mammary carcinoma (diagnosed 4 years before study participation)	Past Treatment Lumpectomy Current treatment None
B	Paranoid (persistent auditory hallucinations)	- Recurrent  Bipolar Disorder Type 2 (in remission) - Panic disorder	Antipsychotic medication -Cognitive Behavioural Therapy	Breast cancer Mammary carcinoma (diagnosed 2 years before study participation)	Past Treatment Radical unilateral mastectomy, chemotherapy, Current treatment Herceptin
C	Undifferentiated (persistent auditory hallucinations)	- Major depressive disorder (in partial remission) - Panic disorder - Bulimia Nervosa (non purging type)	Antipsychotic medication	Bowel Carcinoid (diagnosed 3 years before study participation)	Past Treatment Bowel surgery Current Treatment None
D	Undifferentiated (persistent auditory hallucinations)	- Bipolar Disorder Type 2(in partial remission) - Cannabis Abuse - Opioid Abuse	Antipsychotic medication	Oral Squameous cell carcinoma of left tongue base stage 1 (diagnosed 4 years before study participation)	Past Treatment Modified radical neck dissection, radiation Current Treatment None

 

Interviews were tape recorded and transcribed verbatim to prepare for qualitative analysis (Altheide, Coyle, DeVriese, & Schneider, 2008; Creswell, 2007; Yin, 2009). The current study used thematic analysis to identify unique as well as common experiences and coping strategies in relation to: (a) self-concept; (b) illness perception; (c) perception of illness outcomes; and (d) strategies of coping.  Such analysis has been used in past studies which have examined coping with cancer in other populations, such as young people (Kyngas et al., 2000) and Iranian women (Teleghani, Parsa, & Nasrabadi, 2006).  Such analysis has also been used to study coping with schizophrenia, such as in relation to hope (Klyma, Juvakka, Nikkonen, Korhonen, & Isohanni, 2006) and parents’ coping with children who have schizophrenia (Knudson & Coyle, 2002).

Results
Participant 1
Ms. A is a 74 year old divorced woman living in her own apartment.  She has some post-secondary education and receives her husband’s pension. Her cognitive ability is not impaired (according to her hospital chart). She stated she had the same view of herself before and after cancer diagnosis.   Her illness perception consisted of denial of the schizophrenia diagnosis (but recognition of mental health challenges such as auditory hallucinations), acceptance of the cancer diagnosis, and perception of cancer as the more severe illness.  Ms. A felt positive about the outcome of cancer and expressed how cancer helped her accept her mortality.  Ms. A described problem-focused strategies (such as reading relevant health literature, thinking positive thoughts, talking to cancer survivors, seeking support) and emotion-focused strategies (using relaxation tapes and meditation) to cope with cancer.  To cope with mental health challenges, Ms. A adhered to her physician’s recommendations to take her medication, which is a problem-focused strategy.  Ms. A described coping with cancer as complicating coping with mental health challenges since cancer preoccupied her thoughts.  She described mental health challenges as complicating coping with cancer since she feared her auditory hallucinations would return after cancer diagnosis.

Participant 2
Ms. B is a 38 year old single woman who lives with her sister.  She completed high school and receives disability allowance.  Her cognitive ability is impaired (according to her hospital chart).  Ms. B described feelings of insecurity, anger, sadness, and low self esteem due to having two illnesses.  Ms. B experienced worry regarding cancer surgery and prognosis due to her perception of cancer as the more severe illness.  She also described increased anxiety and hallucinations secondary to cancer and upset stomach due to chemotherapy.  Ms. B expressed negative views regarding the outcome of her illnesses due to anxiety and hallucinations worsening throughout the course of the cancer.  Ms. B utilized problem-focused (such as reading relevant health literature, and adhering to the physician’s recommendations to take medication) and emotion-focused strategies (such as ruminations of suicide, increased worry, wishing the illness would go away) to cope with cancer, but emotion-focused strategies were predominant.  However, to cope with schizophrenia, problem-focused strategies were predominant (exercise, going out with family, drawing pictures, and adhering to her physician’s recommendations to take medication), and she utilized one emotion-focused strategy (wishing schizophrenia would go away).  Ms. B reported her cancer both improved and complicated schizophrenia coping.  Nurses gave Ms. B a relaxation tape after cancer diagnosis and she began to use it to cope with schizophrenia as well, which Ms. B perceived as an improvement; however, cancer complicated coping due to predominant thoughts of cancer.  Ms. B reported schizophrenia complicated coping with cancer, due to an increase in anxiety and positive symptoms of schizophrenia after cancer diagnosis, which distracted from coping in problem-focused ways with cancer.

Participant 3
Ms. C is a 36 year old single woman who lives in her parents’ home.  She has an undergraduate degree and is supported by her parents.  Her cognitive ability is not impaired (according to her hospital chart).  Ms. C reported she did not base her positive self-image on her illnesses.  Ms. C’s perceptions of her illnesses were complicated since her cancer was initially diagnosed as Chron’s disease.  She reported the cancer diagnosis did not change her view of herself, and felt relief for the definitive diagnosis for her bowel symptoms. She perceived cancer as life threatening, and thus worse than schizophrenia.  Ms. C expressed an increase in worry and fear after discovering she had cancer and experienced delusions not all cancer had been removed during surgery.  Ms. C also reported an increase in auditory hallucinations after cancer diagnosis; however, she perceived some of these hallucinations as positive since they comforted her through positive messages.  Regarding illness outcome, Ms. C reported her positive auditory hallucinations decreased after cancer surgery, which she felt was disappointing since they helped her cope with cancer.  Nevertheless, she reported preoccupation with worry over cancer prognosis.  To cope with cancer, Ms. C reported a balance of problem-focused (such as adhering to her physician’s recommendations to take medication and reading relevant health literature) and emotion-focused (such as increased worry and wishing the illness would go away) strategies.  To cope with schizophrenia, Ms. C reported problem-focused strategies (such as washing dishes, going for walks, car rides, adhering to her physician’s recommendations to take medication). Ms. C reported cancer both improved and complicated coping with schizophrenia.  It complicated coping due to a medication change (clozapine was temporarily discontinued) to ease bowel problems caused by cancer, which in turn caused an increase in auditory hallucinations (not all perceived as positive).  Ms. C also reported preoccupation with thoughts about cancer, which distracted from coping with schizophrenia.  Ms. C reported cancer improved coping with schizophrenia since she enjoyed the positive auditory hallucinations, and she enhanced her problem-focused coping after diagnosis (more car rides).  Finally, Ms. C reported schizophrenia complicated how she coped with cancer since the positive voices created distraction from coping with cancer symptoms.

Participant 4
Mr. D is a 37 year old single man who lives with a roommate in a subsidized apartment.   He completed grade 10 education, works part-time as a janitor, and receives disability allowance.  His cognitive ability is impaired (according to his hospital chart).  Mr. D reported his illnesses define his self concept, since he has two.  He described distrust in God for having cancer in addition to mental health challenges.  Mr. D denied a schizophrenia diagnosis (although recognized having mental health challenges), and accepted the cancer diagnosis, which he perceived as the more severe illness.  After cancer diagnosis, Mr. D reported an increase in his depressive symptoms (sadness, feelings of worthlessness, thoughts of suicide), worry, and fear since he perceived no positive outcome from cancer pain or from worsening mental health challenges due to cancer.  To cope with cancer, Mr. D utilized primarily emotion-focused strategies (such as using illegal street drugs, denial, increased worry, wishing the illness would go away), and to a lesser extent problem-focused strategies (such as adhering to  physician’s recommendations and reading relevant health literature).  To cope with schizophrenia, Mr. D described problem-focused strategies (such as adhering to physician’s recommendations to take medication and seeking support from his community mental health worker).  Mr. D reported cancer both improved and complicated coping with schizophrenia.  Mr. D began writing poetry after cancer diagnosis and continued doing so to cope with mental health challenges after cancer removal.  Cancer complicated coping due to increased thoughts of suicide, depressive symptoms, auditory hallucinations, and preoccupation with thoughts about cancer.  After cancer removal, Mr. D reported a decrease in thoughts of suicide.   Mr. D perceived that mental health challenges complicate coping with cancer due to increased fear the mental health challenges would worsen the cancer. 

Discussion
We found that living with comorbid cancer and schizophrenia creates distinct experiences for individuals regarding their self concept, illness perception, illness outcomes, and coping preferences.  When cognitive ability of these individuals is intact, it may help preserve their view of self and may be related to a preference for problem-focused coping, both of which may be protective factors in relation to outcomes.

All participants utilized a wide variety of problem-focused and emotion-focused strategies to cope with cancer; however, all participants utilized primarily problem-focused strategies to cope with schizophrenia, which is consistent with some coping literature (Wonghongkul et al., 2000).  Since the inclusion criteria required participants to have a diagnosis of schizophrenia prior to a cancer diagnosis, this finding may be attributed to living longer with schizophrenia and learning adaptive coping strategies over time.  According to Strous et al (2005), emotion-focused coping is more likely to be used at the exacerbation phase of schizophrenia as well as if the individual is prone to experiencing high levels of emotional distress in their lives, which would fit participants B and D. Individuals with a high amount of social support in their lives are more likely to use problem-focused strategies to cope with the illness (Rudnick, 2001), which would fit participants A and C. 

We found how each illness may affect coping with the other illness.  Cancer complicated and improved coping with schizophrenia.  Cancer preoccupied thoughts for three out of four participants and was perceived as the more severe illness, hence participants spent more time coping with cancer to alleviate stress and symptoms.  Schizophrenia complicated coping with cancer since half the participants reported an increase in positive symptoms of schizophrenia, worry, and fear after cancer diagnosis, which distracted them from addressing their cancer.  The presence of other psychiatric comorbidities may have also impacted coping, such as anxiety leading to more emotion-focused coping.  This has implications for future customized psychosocial interventions, since this population may experience their illnesses in a unique way compared to those diagnosed with only schizophrenia or only cancer.    
This study has limitations. The sample size was small, limiting generalization. Participant recruitment into research was a challenge, as is the case with other research involving people with schizophrenia (Hamann et al., 2007), hence there may have been considerable selection bias, further limiting generalization. The design was exploratory and retrospective, therefore qualifying causal inferences, yet it was conducive to generating hypotheses for future research.

Based on our findings, we hypothesize that: (1) Greater severity of cancer and of positive symptoms of schizophrenia are associated with more emotion focused coping; (2) Level of cognitive functioning and extent of emotion focused coping are negatively correlated; (3) Level of cognitive functioning and extent of problem focused coping are positively correlated. Questions that require further study include, among others, the central question whether schizophrenia impacts differently on coping with cancer, compared to the general population’s coping with cancer. Such research may facilitate the development of effective psychosocial interventions for people with comorbid cancer and schizophrenia and enhance their care.
 
Acknowledgements
The authors would like to thank Dr. Eric Winquist and the local Cancer Center for their collaboration in relation to this project, as well as Dr. Leslie J Bryant and Dr. Joseph D Driskill for their support of and discussions with the principal author.
 

 

References