Breast cancer and severe eating disorder

Gabrielle Morris

49yo female with a large breast cancer requiring mastectomy.

Background

  • Anorexia, known to a psychiatrist and a GP with a specific interest in eating disorders
  • Excellent exercise tolerance
  • Major depression, previous self-harm, and suicidal ideation

Issues

  • Anorexia
    • Recent 300kcal/d intake causing 4kg weight loss, BMI down to 16.5, associated with pedal oedema
    • Initial plan for preop admission to CMN under gastroenterology, with nearby psych support, for NG feeding to improve nutritional state.
    • Patient has declined this and has cooperated with increased intake at home (up to 1500kcal/d at present) with associated weight increase and improved exercise tolerance (runs for exercise)
    • Recent pathology normal
    • Patient requesting bilateral mastectomy and reconstruction to occur at same time as feels she will not cope psychologically with mastectomy.
    • Patient has expressed she does not want the surgeon to speak with psychiatrist

Discussion

  • Has this patient’s psych history and current status been fully elucidated?
    • Alarming that she has declined surgeon and psychiatrist multidisciplinary discussions.
    • Is the psychiatrist fully aware of the current issues and plan?
    • Surgeon should attempt to gain approval from patient to speak with psychiatrist. Explain this to the patient in terms of our standard practice for liaison with specialist in any chronic health condition.
    • Provide patient with a framework for the proposed conversation to allay concerns about privacy regarding mental health history. 
    • Advanced plan for deterioration is required and psychiatrist should be involved. 
    • GP to act as intermediary as a second-line plan.
  • Should this patient have a mastectomy or a bilateral mastectomy with immediate reconstruction
    • Appropriate to proceed to surgery if patient continues current trajectory.
    • Surgeon will consider bilateral mastectomy and reconstruction given significant mental health history
    • Surgeon has advised that mastectomy without recon is preferable from a wound-healing perspective. High risk for wound breakdown, implant loss, and implant infection (especially if non-adherent to nutrition plan postop)
    • Mastectomy can be extremely distressing, even to psychologically well women.
    • Implant loss and wound breakdown are also very distressing. 
    • Infection is relatively easily managed with removal of implant (temporarily or permanently) and IV Abx.
  • Perioperative concerns with anorexia
    • Multiple body systems affected (see review article)
    • Bulimic variant is more physically damaging and may be further complicated by cardio/myotoxicity from emetogenic medications.
    • Risk of cardiac dysrhythmias and fluid overload due to cardiac changes. 
    • Other concerns – pressure area/nerve injury risks, active warming of patient and fluids needed, abnormal gastric emptying (assume unfasted), abnormal responses to NDMRs, concurrent drug or ETOH abuse (including amphetamines for weight loss), concerns about plasma levels of certain drugs which have a high unbound fraction if albumin is low.
  • Where should surgery take place
    • Public hospital with on-site psychiatric support seems most appropriate in event of psychological deterioration postop.
    • Risk of malnutrition and surgical complications will persist for weeks or even months postop. 
  • Postoperative disposition
    • If baseline ECG normal, nil evidence of dysrhythmias intraoperatively, and normal electrolytes, normal ward-based care is appropriate afterwards. 
    • A plan should be in place for daily electrolyte monitoring and telemetry should derangement occur. 

Plan

  • Reasonable to proceed with reconstruction from a purely physiologic perspective, given current nutrition status.
  • Surgeon to attempt to gain consent from patient to speak with psychiatrist. 
  • Consider involving psychiatry liaison service while patient admitted, for mental health wellbeing monitoring.
  • If not already done – check CMP/B12/folate/TFTs
  • NSW Health provides guidance for patients who are admitted to hospital with a decompensation of their eating disorder: https://www.health.nsw.gov.au/mentalhealth/resources/Publications/inpatient-adult-eating-disorders.pdf