Review Article

Cancer Care for Individuals With Schizophrenia

Kelly E. Irwin, MD1,2; David C. Henderson, MD2; Helen P. Knight, BA1; and William F. Pirl, MD, MPH1

Individuals with schizophrenia are a vulnerable population that has been relatively neglected in health disparities research. Despite hav-
ing an equivalent risk of developing most cancers, patients with schizophrenia are more likely to die of cancer than the general popula-
tion. Cancer care disparities are likely the result of patient-, provider-, and systems-level factors and influenced by the pervasive stigma
of mental illness. Individuals with schizophrenia have higher rates of health behaviors linked with cancer mortality including cigarette
smoking. They also have significant medical comorbidity, are less likely to have up-to-date cancer screening, and may present at more
advanced stages of illness. Patients with schizophrenia may be less likely to receive chemotherapy or radiotherapy, have more postoper-
ative complications, and have less access to palliative care. However, opportunities exist for the interdisciplinary team, including medical,
surgical, and radiation oncologists; psychiatrists; and primary care physicians, to intervene throughout the continuum of cancer care to
promote survival and quality of life. This review summarizes data on overall and cancer-specific mortality for individuals with schizophre-
nia and reviews specific disparities across the cancer care continuum of screening, diagnosis, treatment, and end-of-life care. Using a
case, the authors illustrate clinical challenges for this population including communication, informed consent, and risk of suicide, and
provide suggestions for care. Finally, recommendations for research to address the disparities in cancer care for individuals with schizo-
phrenia are discussed. Despite significant challenges, with collaboration between oncology and mental health teams, individuals with
schizophrenia can receive high-quality cancer care. Cancer 2014;120:323-34. V C 2013 American Cancer Society.

KEYWORDS: schizophrenia, health care disparities, cancer, treatment, outcomes.

INTRODUCTION
Although advances in cancer detection, treatment, and supportive care have led to meaningful gains in survival and quality
of life, all patients have not benefited equally. Racial and ethnic minorities, low-income populations, patients without in-
surance, the elderly, and patients who live far from academic cancer centers face lower rates of survival. The American So-
ciety of Clinical Oncology and the American Cancer Society have issued a mandate to better meet the needs of
underserved populations by building awareness and increasing access to quality cancer care.1,2
Individuals with severe mental illness, such as schizophrenia, are also at risk of increased mortality due to cancer,
yet to the best of our knowledge, patients with cancer and comorbid schizophrenia have been relatively neglected in can-
cer health services research. Schizophrenia is a devastating psychiatric illness that affects 1% of the US population and
causes changes in thinking, perception, and behavior that contribute to social isolation and difficulty sustaining employ-
ment. Patients with schizophrenia experience positive symptoms, including delusions and hallucinations; negative symp-
toms, including low motivation and social withdrawal; and cognitive symptoms, including deficits in verbal memory,
attention, and executive function. Effective treatments target many of the symptoms of schizophrenia and there is con-
siderable variability in functioning. However, cognitive deficits are the biggest obstacle to achieving an independent and
productive lifestyle, and these deficits are refractory to current drug treatments.3 Importantly, individuals with schizo-
phrenia reportedly die between 15 and 25 years earlier than the general population.4,5 This mortality gap is increasing,
and the majority of premature deaths are due to medical illnesses, including cardiovascular disease and cancer.6-9 Lead-
ers in mental health treatment emphasize the importance of designating patients with severe mental illness as a vulnera-
ble population.10,11 Without increased awareness and targeted intervention, cancer disparities in individuals with
schizophrenia will likely worsen over time.
This review summarizes known disparities in cancer prevention, diagnosis, treatment, and end-of-life (EOL) care among
individuals with schizophrenia. We discuss challenges in caring for patients with schizophrenia, highlight points of interven-
tion, and suggest research priorities.

Corresponding author: Kelly E. Irwin, MD, Massachusetts General Hospital Cancer Center, Center for Psychiatric Oncology and Behavioral Sciences, 55 Fruit St,
Boston, MA 02114; Fax: (617) 643-9913; kedwards2@partners.org
1
Massachusetts General Hospital Cancer Center, Center for Psychiatric Oncology and Behavioral Sciences, Boston, Massachusetts; 2Massachusetts General Hospital
Schizophrenia Program, Massachusetts General Hospital, Boston, Massachusetts

DOI: 10.1002/cncr.28431, Received: August 9, 2013; Revised: September 3, 2013; Accepted: September 10, 2013, Published online October 21, 2013 in Wiley
Online Library (wileyonlinelibrary.com)

Cancer February 1, 2014 323

Review Article
Cancer Incidence
Data from recent population-based registries have sug-
gested that cancer incidence is similar in individuals with
and without schizophrenia when controlling for competing
causes of mortality, decreased life expectancy, and poorer
health behaviors.12,13 Moreover, multiple studies, although
not all, have found that risk may vary by cancer type. Indi-
viduals with schizophrenia demonstrate a higher risk of
developing lung cancer, and smoking likely accounts for a
significant portion of this risk.14,15 Some studies have iden-
tified a modestly elevated risk of breast cancer in individu-
als with schizophrenia, which may be impacted by
nulliparity, obesity, and exposure to antipsychotics.15-17
Cancer Mortality
Population-based studies in multiple countries with uni-
versal health care coverage have provided robust evidence
that patients with schizophrenia are 1.5 to 2 times more
likely to die of their cancer than patients without mental
illness.8,12,18 Studies by cancer type have further demon-
strated that patients with schizophrenia face elevated risk
of dying of lung, breast, and colon cancers.14
This increased mortality is likely influenced by
patient-level, provider-level, and systems-level factors.
Individuals with schizophrenia have high rates of smoking,
obesity, and substance abuse. Greater than two-thirds of
excess deaths due to natural causes in patients with schizo-
phrenia occur as a result of smoking-related diseases such
as lung cancer.19 In addition, high rates of medical comor-
bidity including cardiovascular disease, chronic obstructive
pulmonary disease, and diabetes11 likely affect the ability
of these individuals to tolerate cancer treatment. Access to
quality care also contributes to cancer disparities.6,12 In a
large Swedish study of individuals with schizophrenia, the
elevated mortality due to lung, breast, and colon cancers
was explained primarily by underdetection. Despite
increased contacts with the health care system, patients
with schizophrenia were less likely to have been diagnosed
with cancer > 30 days before death.8 A recent, large, retro-
spective study14 found significantly increased cancer-
related mortality in patients with psychiatric illness, and
this disparity was more pronounced in individuals with
schizophrenia. Compared with the general population,
patients with psychiatric illness were more likely to present
with metastatic disease, had lower rates of surgery, and
received fewer chemotherapy sessions.14
Stigma
Stigma toward patients with schizophrenia likely worsens
cancer disparities at multiple levels.19 Stigma is a combi-
324
nation of stereotyped beliefs, prejudiced attitudes, and
discriminatory behaviors targeting a devalued popula-
tion.20 Stereotypes are held by the general public, health
care providers, and people with mental illness. Common
stereotypes include that individuals with schizophrenia
are to blame for their poor health, are less adherent to
medical recommendations, and more likely to be violent.
Self-stigma refers to the process of internalizing a negative
stereotype and applying it to oneself.21 People with schiz-
ophrenia report high rates of health care discrimina-
tion.22-24 Individuals with schizophrenia may anticipate
that they will be discriminated against by health care pro-
viders and therefore may be less likely to seek medical care
or disclose physical symptoms.
At the provider level, the stigma of mental illness
also affects the physician-patient interaction. “Diagnostic
and treatment overshadowing” refers to the difficulty of
diagnosing and treating a medical illness in patients with a
comorbid psychiatric illness. Providers may be more likely
to attribute medical symptoms to the psychiatric illness,
less likely to refer patients to specialized treatment, and
less likely to address barriers to optimal care. Disparities
in care may be more pronounced when patients have a bi-
zarre affect or poor hygiene or when there is clinical uncer-
tainty regarding the best treatment.25 For example,
oncologists who believe that the majority of patients with
schizophrenia lack the ability to make medical decisions
may refer fewer patients with schizophrenia to clinical tri-
als. Concern regarding violence in individuals with schiz-
ophrenia may also influence oncology care. One case
series describing surgical care for patients with lung cancer
and schizophrenia emphasized the importance of restrict-
ing surgical candidates to patients with schizophrenia who
are at low risk for agitation.26 At the systems level, patients
are often treated for schizophrenia in mental health clinics
that are physically separate from general hospitals and use
different electronic records. This separation may impede
communication between oncologists and psychiatrists
and could contribute to delays in care.
Introduction of the Model
Figure 1 illustrates factors that may contribute to poorer
outcomes for patients with schizophrenia and cancer. We
hypothesize that interrelated patient-based, provider-
based, and systems-based factors, influenced by mental
health stigma, may impact cancer prevention, diagnosis,
treatment, and EOL care. This model also provides a
framework for understanding how strategies that address
patient-based, provider-based, and systems-based issues,
including early psychiatric consultation and facilitating
Cancer February 1, 2014

Figure 1. Schematic is shown illustrating disparities in cancer care for patients with schizophrenia. Throughout the continuum of
cancer care, the stigma of mental illness influences interrelated patient-level, provider-level, and systems-level factors, ultimately
impacting quality of life and survival.
communication among oncologists, psychiatrists, and pri-
mary care providers (PCPs), may improve the quality of
care for patients with schizophrenia and cancer.
CANCER PREVENTION
Addressing Health Behaviors
Targeting smoking in individuals with schizophrenia may
impact overall and cancer-specific mortality. Although
the prevalence of smoking in the United States has
decreased from 42% to 19% since the 1960s, approxi-
mately 60% to 80% of patients with schizophrenia
smoke.27 They smoke more cigarettes and inhale more
deeply, factors associated with lung cancer risk.28 Stigma
likely contributes to cigarette smoking in mental illness:
psychiatrists and PCPs may believe that quitting smoking
exacerbates psychiatric symptoms or that patients with
schizophrenia are unable to quit. However, motivation to
quit in patients with schizophrenia is approximately the
same as in the general population.29 There is strong sup-
port for buproprion for smoking cessation in patients
with schizophrenia, particularly when paired with cessa-
tion counseling.30 With regard to obesity, one group-
based behavioral health intervention designed for people
Cancer February 1, 2014
Cancer Care for Schizophrenia/Irwin et al
with serious mental illness led to sustained weight loss at
18 months.31
Cancer Screening
Individuals with schizophrenia are less likely than those
without mental illness to have up-to-date screening for
breast, cervical, and colorectal cancer, independent of
race, income, education, insurance coverage, and number
of visits to a PCP.32-34 In one study, despite higher rates
of smoking and more frequent PCP visits, patients with
schizophrenia were 5 times less likely to have had a Papa-
nicolaou test within the past 3 years.35 Veterans with psy-
chiatric illness including schizophrenia had lower rates of
screening for colorectal cancer after adjusting for fre-
quency of PCP visits.36 One study of older homeless
adults with serious mental illness found lower rates of
colorectal cancer screening and fewer medical visits com-
pared with homeless individuals with depression.37
Patient-level, provider-level, and systems-level fac-
tors contribute to low rates of cancer screening (Fig. 1).
Among patients, cognitive symptoms (eg, impaired atten-
tion and executive function) may impact understanding
of the risks and benefits of screening; positive symptoms
(eg, paranoia) may intensify fear of an unfamiliar
325
Review Article

TABLE 1. Diagnosis and Treatment of Cancer in Patients With Schizophrenia

Study and Location Study Design Population Key Findings and Implications Limitations

Inagaki 200640 Retrospective Patients with schizophrenia - Ability to treat associated with se- Small case series
Japan case series and cancer (n 5 14), verity of psychiatric symptoms and
divided into patients who whether subjects were hospitalized
accepted treatment (n 5 7) - Patients’ ability to receive diagnosis
and those who refused or and understand illness contributed
interrupted treatment to treatment delays.
(n 5 7) - Consultation-liaison psychiatrists
played critical role.
Mateen 200841 Retrospective Patients with schizophrenia - Psychiatric symptoms affected Small case series
United States case series and potentially curable lung treatment of 2 patients; both
cancer (n 5 17) received some treatment.
- Chart review indicated communica-
tion within interdisciplinary team of
providers, careful consideration of
ethical issues.
O’Rourke 200842 Retrospective Patients with esophageal - Psychiatric illness associated with - Small subset of patients with
United States chart review cancer (n 5 160). Sub- delay in cancer diagnosis and late- psychotic disorders limited
group with psychiatric stage disease at diagnosis comparisons by diagnosis.
comorbidities (n 5 52) - Patients with psychiatric illness - Conducted in VA population,
were less likely to undergo surgery. which may limit
- Psychosis (small n) not a risk factor generalizability
for higher morality
- Worse outcomes for patients with
psychiatric illness potentially due to
provider-related factors (eg, attribut-
ing symptoms to mental illness) and
patient-related factors (eg, vague
report of symptoms)
Sharma 201043 Prospective Patients with schizophrenia - Thirty of 37 patients presented with No control group
United Kingdom case series and breast cancer (n 5 37) early-stage disease. Majority of
patients were offered and received
standard therapy.
- No one refused surgery or radio-
therapy.
- Chemotherapy and antiemetic regi-
mens did not need to be altered.
- Seven patients were offered clinical
trial participation: 5 consented and
2 received standard care.
- All subjects received antipsychotics
during cancer treatment.
- Treatment was not highly burden-
some for oncology team.
Hwang 201244 Retrospective Patients with schizophrenia - High rates of palpable breast mass - Conducted in predominantly
United States case series and breast cancer, eligible and nipple changes at diagnosis male VA population, which
for adjuvant chemotherapy - Majority of patients received mas- may limit generalizability
(n 5 55: 18 males and 37 tectomy rather than lumpectomy. - Missing data were not
females) - 85% of patients were offered adju- accounted for.
vant chemotherapy or endocrine - Unclear why providers did
therapy; one-third refused or were not recommend chemother-
nonadherent. apy or hormonal therapy
- Two-thirds of patients were offered and unclear why patients
adjuvant endocrine therapy; 8 refused to adhere with the
patients refused or were noncompli- recommended treatment
ant. - No control group
- 9% of sample had homicidal idea-
tion; 31% had documented suicidal
ideation.
- Documented past suicide attempts
and staff assaults in minority of
patients
- Some patients refused
antipsychotics.
Baillargeon 201145 Retrospective Patients with colon cancer - Patients with psychiatric illness - Limited generalizability to
United States population-based (n 5 80,607). Subgroup were more likely to have an patients aged <67 y
record linkage with prior mental disorder unknown cancer stage and to be - Did not include information
diagnosis (n 5 20,699) diagnosed at autopsy. on medication use

326 Cancer February 1, 2014

 Cancer Care for Schizophrenia/Irwin et al

TABLE 1. Continued

Study and Location Study Design Population Key Findings and Implications Limitations

analysis using - Patients with psychotic disorders

SEER-Medicare were more likely to receive no
database chemotherapy (73%) compared
with patients without psychiatric ill-
ness (39%).
- Patients with psychiatric illness had
elevated overall and cancer-specific
mortality, not accounted for by dif-
ferences in receipt of chemother-
apy.
- Disparities in diagnosis, treatment,
and survival were particularly strong
in patients with psychotic disorders.
Kisely 201314 Retrospective Patients with psychiatric - Patients with schizophrenia had - Did not account for medical
Australia population-based illness and cancer same cancer incidence but signifi- comorbidity
record-linkage (n 5 6,586). Subgroup with cantly increased cancer mortality - Did not account for health
analysis schizophrenia and cancer (males: rate ratio, 2.0 [95% CI, behaviors
(n 5 106: 50 males and 1.51–2.64] and females: rate ratio, - Did not include information
56 females) 1.68 [95% CI, 1.29–2.18]). on medication use
- Patients with psychiatric illness
were less likely to undergo surgery
for colorectal, breast, and cervical
cancers; received fewer chemother-
apy sessions; and were less likely
to receive radiotherapy for breast,
colorectal, and uterine cancers.
Obuchi 201326 Retrospective case Patients with schizophrenia - Schizophrenia was not an automatic - Small case series
Japan series (all of whom were institu- exclusion criteria for surgery for - All patients were institution-
tionalized) and lung cancer lung cancer. alized.
(n 5 11) -Patients were selected to have low - Selection bias toward
risk of agitation, otherwise unable patients who were antici-
to meet needs for behavioral man- pated to be calm and coop-
agement erative with care
- Acceptable level of postoperative
complications: respiratory and
psychiatric
Farasatpour 201346 Retrospective chart Patients with schizophrenia - Many patients presented with large Same VA sample as study by
United States review with prese- and breast cancer (n 5 56: breast masses, nipple retraction, Hwang44 with limited gener-
lected control 18 males and 38 females) and metastatic disease at diagno- alizability and dispropor-
group sis. tionate amount of male
- Minority of patients had significant patients
delays between diagnosis and start
of treatment.
- Mastectomy was more common
than lumpectomy, which contrasted
with control population without
mental illness.
- Delays in adjuvant chemotherapy
were in part due to postoperative
complications.
- Delays were associated with disrup-
tive behavior, not receiving antipsy-
chotics, and ongoing psychotic
symptoms.

Abbreviations: 95% CI, 95% confidence interval; SEER, Surveillance, Epidemiology, and End Results; VA, Veterans Affairs.

radiation technologist; and negative symptoms (eg, low
motivation) may decrease the likelihood of attending
follow-up appointments. At the systems level, continuity
of care with a PCP is associated with higher rates of
screening in the mentally ill. However, patients with
schizophrenia are less likely to have regularly scheduled
health maintenance visits.38 Psychiatrists, therefore, can
play a critical role in facilitating cancer screening by moni-
toring whether patients are up to date, facilitating refer-
rals, or collaborating with a PCP to provide screening.
Training and support are needed to assist psychiatrists in
this role. In the case of a positive screening result, it is also
necessary to have a care plan that promotes a rapid diag-
nostic workup and initiation of treatment.39

Cancer February 1, 2014 327

Review Article
DIAGNOSIS AND TREATMENT
To our knowledge, few studies to date have examined dis-
parities in the diagnosis and treatment of cancer in
patients with schizophrenia (Table 1).14,26,40-46
Population-based research and clinical case series have
found that patients with schizophrenia frequently present
with advanced disease at the time of diagnosis. Small case
series have suggested that patients with schizophrenia may
be more likely to refuse treatment and to have behaviors
that may disrupt cancer care. However, retrospective case
series have demonstrated that it may be possible for
patients with schizophrenia to receive state-of-the-art can-
cer care.41,43 This work highlights the importance of early
psychiatric consultation to guide potential modifications
to the cancer treatment plan, facilitate illness understand-
ing, assess capacity to consent, assess risk of self-harm and
violence, and consider medication interactions and post-
operative complications.
Diagnosis
Patients with schizophrenia may experience delays in the
diagnosis of cancer and present with more advanced dis-
ease. In a small Veterans Affairs (VA) sample of individu-
als with schizophrenia who were diagnosed with breast
cancer, many patients presented with large breast masses
and associated skin and nipple changes. Nearly 50% of
patients with schizophrenia and cancer had significant
delays between the diagnosis of cancer and initiation of
treatment.44,46
Multiple authors have questioned whether misattri-
bution of early cancer-related symptoms to psychiatric
causes may contribute to possible delays in diagnosis.
Diagnosing cancer in patients with schizophrenia may
present unique difficulties, particularly when the first
signs are neuropsychiatric. Similarly, patients with psy-
chotic disorders may have “alarm symptoms” such as diffi-
culty swallowing for longer time periods than the general
population before a diagnosis of esophageal cancer is
made.42 It is critical to have a high index of suspicion for
medical causes when evaluating physical symptoms in
patients with schizophrenia.
Treatment
Surgery
Patients with psychiatric illness and esophageal and colo-
rectal cancers may be less likely to undergo recommended
surgery (Table 1).14,26,40-46 Moreover, patients with schiz-
ophrenia may experience worse surgical outcomes. After
controlling for medical comorbidity and type of proce-
dure, patients with schizophrenia were found to have
328
nearly 3 times greater rates of mortality 30 days after sur-
gery.47 Patients with schizophrenia appear to experience a
higher rate of postoperative complications including re-
spiratory failure, sepsis, deep venous thrombosis, pulmo-
nary embolism, paralytic ileus, stroke, and postoperative
delirium.48
Contributing factors at the patient level include the
severity of psychiatric symptoms, medical comorbidity,
medication interactions, and decreased pain sensitivity.
For example, disorganization may impede the patient’s
ability to provide a coherent history, paranoia may con-
tribute to avoidance of a physical examination, and nega-
tive symptoms may lead to a lack of awareness of a large
breast mass. It is interesting to note that despite a national
movement toward breast-conserving management, the
majority of patients with schizophrenia in a prospective
cohort study in England and a VA study underwent mas-
tectomies rather than lumpectomies.43,44 Although modi-
fication of a treatment plan to minimize the need for
radiotherapy may sometimes make clinical sense, requir-
ing a more extensive surgery within the context of greater
medical comorbidity may contribute to postoperative
complications and elevated mortality.
Surgeons have advocated for more careful preopera-
tive assessment, attention to pain control, and involve-
ment of psychiatric consultants from the point of
diagnosis. Partly due to unfamiliarity and inadequate
training, the surgery team may experience challenges in
communicating with patients with schizophrenia, whose
thoughts may be disorganized.49 Case series of patients
with schizophrenia and lung and breast cancers have high-
lighted the value of consulting psychiatry to assess for risk
of harm to the patient and staff, and to select those
patients for surgery who were at low risk of agitation.26,46
Chemotherapy, endocrine therapy, and
radiotherapy
Kisely et al found that psychiatric patients in Western
Australia received fewer chemotherapy sessions than
patients without mental illness, although it is unclear if
that difference was clinically significant.14 In addition,
psychiatric patients with breast, colorectal, and uterine
cancers received less radiotherapy than the general popula-
tion.14 In the United States, older adults with American
Joint Committee on Cancer stage III colon cancer and a
psychiatric disorder, particularly schizophrenia, were
more likely to receive no chemotherapy compared with
patients without mental illness, after adjusting for socioe-
conomic status and medical comorbidity. However, this
disparity did not explain the increased overall and colon
Cancer February 1, 2014
 Cancer Care for Schizophrenia/Irwin et al

TABLE 2. The Initial Oncology Consultation for Patients With Schizophrenia and Cancer
Identify supports and build an interdisciplinary team
Facilitate communication and promote
illness understanding
Assess common comorbidities and perform a basic risk
assessment
Consider modifications to the treatment plan that may pro- 1. Is better control of psychiatric symptoms needed before the start of cancer treatment?
mote adherence and cooperation with care
1. Who accompanies the patient to the visit?
2. Does the patient have a psychiatrist? A trusted primary care provider? Are there other
key members of the mental health care team (social worker, case manager, group home
staff, visiting nurse)?
3. Who does the patient trust (ally and emergency contact)?
4. Who manages the patient’s medications? The patient? Family member? Group home
staff?
5. When available, consult psychiatry and social work at time of diagnosis.
1. Assume capacity to engage in decision-making about cancer treatment and end-of-life
care.
2. Tailor communication to the patient with likely cognitive deficits and concrete thinking.
a. When possible, schedule additional time to discuss recommendations and write down
specific changes.
b. Avoid statistics and hypothetical scenarios and focus on the individual patient and
here and now.
3. Involve other supports but also speak directly to the patient.
4. Establish a system of communication between appointments: explain how to leave mes-
sages and identify a specific person the patient can call with questions.
5. Combine future oncology appointment with social work, nursing, or psychiatry visits to
provide opportunities for the patient to ask questions and reinforce treatment
recommendations.
1. Assess for depression and substance abuse.
2. Assess for common medical comorbidities (eg, cardiovascular disease, chronic obstruc-
tive pulmonary disease, and smoking).
3. Consider potential medical interactions and medications that may be deliriogenic.
4. Complete a basic risk assessment. History of self-harm or violence? Access to firearms?
Currently hopeless or suicidal?
a. Is the patient actively psychotic, disorganized, or suicidal?
b. Is the patient delirious or attentive and able to listen without distraction?
c. Does the patient report taking his or her medications (particularly antipsychotics) as
prescribed?
2. Does it make sense for the patient to have a brief hospitalization for the first round of
chemotherapy or a prolonged rehabilitation stay after surgery?
3. Can the patient visit the infusion suite or site of radiotherapy prior to treatment?
4. Try to maintain a familiar nurse and care team to build trust and comfort over time.
5. Are there other barriers such as obtaining transportation or coordinating multiple appoint-
ments to complete staging?

cancer-specific mortality observed in patients with psy-
chotic disorders.45 Adherence to treatment with tamoxi-
fen in patients with psychiatric illness is largely unknown.
Findings from smaller studies of breast cancer treat-
ment conflict with respect to whether providers are less
likely to offer chemotherapy to patients with schizophrenia
and whether patients with schizophrenia are more likely
than other patients with breast cancer to refuse treat-
ment.44,46 Sharma et al emphasized that there was no need
to modify the standard chemotherapy regimen if adminis-
tered in a setting with trained support staff including nurses
and social workers and available psychiatric consultation.43
For patients with significant cognitive deficits and barriers
to adherence, a brief inpatient hospitalization may enable
the timely delivery of chemotherapy or radiotherapy.
Where available, patients with a history of agitation may be
best served in a unit with expertise in the management of
psychiatric and medical illness or alternatively, with close
follow-up by psychiatric consultants and additional train-
ing of oncology nurses. If patients have uncontrolled psy-
chotic symptoms, optimizing psychiatric treatment first
may make it possible for patients to receive cancer-directed
therapy. Psychiatrists have expertise in establishing trust
and communicating complex treatment recommendations
in language that is tailored to the individual patient. When
feasible, involving the patient’s sources of social support,
whether family, friends, or members of the mental health
care team, may make it possible for patients to complete
recommended treatment (Table 2).
Referral to clinical trials
Individuals with schizophrenia experience some of the
same underlying barriers to clinical trial participation that
affect other vulnerable groups,50,51 including challenges
with trust, difficulty with communication, high medical
comorbidity, and being less likely to be treated at an aca-
demic cancer center. In addition, patients with schizo-
phrenia may be unnecessarily excluded from trials due to
questions about their ability to provide informed consent.
In the prospective cohort study of patients with breast

Cancer February 1, 2014 329

Review Article
cancer and schizophrenia, the authors suggested that
patients with severe mental illness may be excluded from
clinical trials before conducting a capacity assessment.43
Importantly, individuals with schizophrenia may
differ dramatically in their ability to consent. Further-
more, capacity can change over time and needs to be
assessed based on the risks and benefits of each treatment
decision. Cognitive impairments, including deficits in
verbal memory and processing speed, affect the capacity
to provide informed consent more than psychotic symp-
toms such as hallucinations and delusions. Patients with
delusions may be able to engage in a conversation focused
on the present and the specific aspects of their cancer.
With additional time spent explaining research, patients’
capacity to consent can improve.52 In fact, patients with
schizophrenia may benefit from the structured care, mon-
itoring, and increased contact with oncology staff in a
clinical trial, which may facilitate treatment adherence.53
EOL care
Patients with schizophrenia may receive lower-quality
EOL care. In a Canadian study, individuals with schizo-
phrenia were twice as likely to reside in a nursing home
and were less likely to be referred to palliative care or be
prescribed opiates to treat pain compared with matched
controls during the last 6 months of life. Patients with
schizophrenia also had decreased contact with their outpa-
tient psychiatrists.54,55 In contrast, a study from the VA
system found that patients with schizophrenia and cancer
had longer hospice stays and were more likely to have
documented do not resuscitate orders than patients with-
out major mental illness.56 This finding may point to the
value of the integrated care provided in the VA system.
Individuals with schizophrenia may be excluded from
making decisions about their EOL care in part due to pro-
vider concerns about their emotional fragility and compe-
tence.57 However, Foti et al found that individuals with
severe mental illness are generally interested in EOL care dis-
cussions and are able to articulate their preferences.58 Disrup-
tions of mental health care due to physical illness may
worsen the symptoms of mental illness, underscoring the im-
portance of advance care planning in this population.57,58
CHALLENGES IN CLINICAL CARE
Although level of functioning varies, individuals with
schizophrenia present complex challenges to cancer care at
the patient, provider, and systems levels, as depicted in
Figure 1. Individuals with schizophrenia may have a with-
drawn or bizarre affect that makes it difficult to build an
alliance and may communicate their medical history in a
330
vague, disorganized, or incomplete way. Patients with
schizophrenia have higher rates of medical comorbidity
and smoking, which may affect their ability to tolerate
cancer treatment and increase the likelihood of postopera-
tive complications. Patients may not disclose a diagnosis
of schizophrenia or know the names of their medications.
Frustratingly, psychiatrists may be seen in separate health
care systems with different electronic medical records.
These challenges can be overwhelming for the oncol-
ogist, and at a minimum, frequently require additional
time and a thoughtful, collaborative approach to care.
However, encouragingly, many patients with schizophre-
nia and cancer can cope well with their disease. Early psy-
chiatric consultation and communication with the
patient’s outpatient mental health team are key strategies
to optimize cancer outcomes and enable oncologists to
focus on the delivery of quality cancer care. At the time of
diagnosis, there are several steps that oncologists can take
to assess the needs of the patient with schizophrenia and
design a treatment plan that can be modified over time
(Table 2). If patients are currently connected to care,
establishing communication with mental health providers
and PCPs may be particularly useful, given that patients
may not provide a full medical or psychiatric history.
When available, family members may also provide impor-
tant collateral history, serve as advocates for the patient, or
act as surrogate decision-makers if needed.
Capacity Assessment
A diagnosis of schizophrenia does not automatically
render a person unable to make decisions about his or her
own medical care. Ethically, it is important to start from
the assumption that patients can understand treatment
options and express consistent choices. Capacity is specific
and varies based on the complexity of the medical decision
and the risks and benefits of accepting or refusing treat-
ment. In addition, oncologists and psychiatrists, when
available, have the responsibility to continue to educate
patients to maximize the patient’s ability to provide con-
sent. Given low social support, if a patient is unable to
consent, it also may be challenging to identify a surrogate
decision-maker or establish a health care proxy.59 Chal-
lenges with consent and untested assumptions that
patients with psychotic disorders cannot provide consent
may delay or preclude surgery, chemotherapy, or radio-
therapy, and prevent participation in clinical trials.
Risk of Suicide
To the best of our knowledge, there is little research to
date exploring the risk of suicide in patients with both
Cancer February 1, 2014

schizophrenia and cancer. Separately, however, both
schizophrenia and cancer are associated with an increased
risk of suicide. Patients with schizophrenia are 5 times
more likely to complete suicide than the general popula-
tion.60 The risk is highest early in the course of illness
and when patients are actively psychotic, particularly
when experiencing beliefs that they are being persecuted
or hearing voices telling them to harm themselves.
Patients with cancer are also more likely to commit sui-
cide.61 A recent study demonstrated a 5-times elevated
risk of suicide in patients with lung cancer, with the
highest risk occurring within 3 months of diagnosis and
among older, white males. Although suicide is more
likely when prognosis is poor, a significant percentage of
suicides occur among patients whose cancer can be cured.
Patients with life-threatening illness appear to be vulnera-
ble to suicide after learning of their prognosis and when
experiencing higher distress.62 In the case of patients
with schizophrenia and cancer, it is important to be
aware of patients’ past history of self-harm, to monitor
them throughout the course of illness, and to have a low
threshold to involve psychiatric consultation.
Risk of Violence
The absolute risk of violence in patients with schizophre-
nia is low although mildly increased compared with the
general population. The risk is higher in patients with a
previous history of assault, past victimization by violence,
comorbid substance use, and uncontrolled psychotic
symptoms.63 Treating psychotic symptoms and regularly
monitoring for substance abuse are important ways to
decrease the risk of future violence.64
Homelessness
Schizophrenia is a significant and independent risk factor
for homelessness. Homeless individuals have high rates of
medical illness, substance abuse, and cigarette smoking,
and cancer is a leading cause of mortality in this popula-
tion. One population-based study in Boston found that
homeless persons aged 45 years to 64 years have double
the risk of dying of cancer. As expected given smoking
rates, lung cancer accounted for a high percentage of those
deaths.65 To the best of our knowledge, homeless persons
with schizophrenia who are not engaged in mental health
treatment are not included in the majority of studies
regarding mortality and mental illness. The combination
of homelessness and schizophrenia likely compounds the
vulnerability of this population.
To address disparities in care, advocates for the
homeless have emphasized the need to provide integrated
Cancer February 1, 2014
Cancer Care for Schizophrenia/Irwin et al
and flexible care that targets medical, psychiatric, and
social needs.66,67 For example, the Boston Health Care for
the Homeless Program includes a street team with a full-
time PCP and psychiatrist who work with patients to
obtain cancer screening. Given that homeless individuals
have low rates of preventive care and a higher use of emer-
gency services, when feasible, episodes of acute care should
be used to address acute and chronic health concerns. A
longer hospitalization may be necessary to complete cancer
staging and coordinate an interdisciplinary treatment
plan. Homeless patients, particularly those with comorbid
schizophrenia, may need respite care to tolerate a course of
chemotherapy usually provided in the outpatient setting.
EOL care for homeless adults likely requires creative solu-
tions such as shelter-based palliative care.68
CASE ILLUSTRATION
T.G. was a 66-year-old African American woman with
paranoid schizophrenia. She lived in a single room occu-
pancy facility in an urban neighborhood and identified
her sister (last seen 15 years prior) as her closest support.
She managed her own medications and was wary of any
changes. She had attempted suicide 15 years previously.
She had smoked 2 packs of cigarettes per day since age 18
years but did not drink alcohol or use drugs. She was fol-
lowed by a PCP at an academic hospital and a psychiatrist
at a community mental health clinic. She had been receiv-
ing antipsychotics for > 20 years with significant
improvement in auditory hallucinations. Residual cogni-
tive symptoms sometimes impacted her ability to remem-
ber details about her medications. During visits, she
appeared withdrawn and rarely smiled.
She initially presented to her PCP with arm pain.
When a full review of systems was gathered, she men-
tioned a persistent cough. Due to her smoking history,
her PCP ordered a chest x-ray, which showed a new large
lung mass. She was diagnosed with metastatic disease and
a pericardial effusion causing early cardiac tamponade.
She was admitted, had consults from radiation and medi-
cal oncology physicians, and was discharged to a rehabili-
tation facility for 6 weeks to complete palliative
radiotherapy. After returning home, she missed her first 3
outpatient appointments with palliative care. She did not
see her psychiatrist after her cancer diagnosis but did fol-
low up with her PCP and quit smoking.
Her medical oncologist referred her to the cancer cen-
ter psychiatrist given questions about her understanding of
the risks of chemotherapy. She was guarded initially, but
continued to meet the psychiatrist every 2 weeks. At her
third visit, she shared her fear of damnation and her belief
331
Review Article
that her thoughts could be read by her physicians. She
shared passing thoughts of wanting to die. Her physical
symptoms progressed and, rather than calling her oncolo-
gist, she left multiple messages for her psychiatrist. She
wanted to receive chemotherapy but did not want side
effects. After many conversations with providers and a con-
ference call with her sister, she declined additional chemo-
therapy. T.G. had many concrete questions about hospice
(will I die earlier, can I continue to see you, will I have to
stop medications). With time to ask these questions, she
agreed to hospice care. She began with home visits with a
visiting nurse, social worker, and chaplain who spoke with
T.G.’s psychiatrist regarding her fears of dying and
thoughts of suicide. Her antipsychotics were continued.
When her physical symptoms progressed, she transitioned
to inpatient hospice care. Her PCP, psychiatrist, and oncol-
ogist spoke with her by telephone until her death.
T.G.’s case highlights the value of an integrated team
of providers collaborating to provide cancer treatment
while working to support the patient’s goals. T.G. had a
longitudinal relationship with a PCP, who during a sick
visit for an unrelated symptom took additional steps to per-
form workup on a cough that might otherwise have been
ignored. A prolonged rehabilitation stay made it possible
for her to complete a beneficial course of palliative radio-
therapy. Her physicians questioned her capacity to accept
or refuse chemotherapy, and more broadly, her ability to
cope at home as her physical illness progressed with limited
support. With time to ask questions and build trust in new
physicians, T.G. was able to make a clear choice to priori-
tize her quality of life and stop chemotherapy. Her team
worked together to support her wishes and maintain com-
munication with her after her transition to hospice care.
Consulting psychiatry when a patient with schizo-
phrenia is diagnosed with cancer may have the potential
to improve cancer treatment. Although antipsychotics are
effective at targeting hallucinations, subtle delusions and
mistrust frequently persist, and patients experience chronic
cognitive deficits. Psychiatrists are trained to establish a
therapeutic alliance; elucidate the patient’s understanding
of cancer and goals for ongoing care; and facilitate com-
munication with the interdisciplinary team, patient, and
family. It can be helpful to begin by addressing the needs
that the patient prioritizes such as improved control of
physical symptoms. Psychiatrists can provide education
about the patient’s cancer in a clear, individualized, and
concrete manner before assessing the patient’s understand-
ing of treatment and therefore frequently increase the
patient’s capacity to consent to treatment. Psychiatrists
can also assess whether a patient’s psychiatric medications
332
are optimized and safe with the current cancer-directed
treatment. In collaboration with oncologists (Table 2),
psychiatrists may make recommendations to promote
cooperation with care such as limiting the size of the treat-
ment team and ensuring that antipsychotics are continued
postoperatively. Patients with schizophrenia are frequently
socially isolated. It may be necessary to think about earlier
transitions to hospice care or other creative ways to enable
patients to access palliative care services.
Delirium is a common consideration in patients
with cancer. Distinguishing features of delirium include a
primary disturbance in attention and=or level of alertness
that is generally preserved in psychosis. Practically, it is
important to have a low threshold to workup new symp-
toms that raise concern for delirium within the context of
cancer care, particularly in patients with schizophrenia
who may be hesitant to discuss new symptoms or who
may describe them only vaguely.
STRATEGIES TO IMPROVE CARE
Clinical Care
Although individuals with schizophrenia experience dispar-
ities in cancer care, opportunities to improve care can be
identified at the patient, provider, and systems level. At the
patient level, excess mortality may be reduced by evidence-
based interventions targeting smoking cessation and weight
loss. At the provider level, care could be strengthened by
improving communication among oncology and mental
health providers. From a systems perspective, clinical
guidelines and a clear delineation of responsibility for can-
cer screening are needed. Different models of integrated
medical and psychiatric care have demonstrated promise in
meeting the needs of patients with schizophrenia. To our
knowledge, models to improve cancer care for this popula-
tion have not been studied in health services research. Clini-
cal experience and case series point to the importance of
involving the psychiatrist at the time of diagnosis to help to
design and adapt the treatment plan. Community-based
cancer navigators have helped to address disparities in can-
cer screening and decrease delays in treatment in other vul-
nerable populations.69 Studies have demonstrated that the
use of navigators for patients with serious mental illness can
lead to higher rates of preventive health care.70,71 Models of
care have used both nurse care managers and peer recovery
specialists who partner with individuals with schizophrenia
to help to negotiate a complex health system.72,73 Targeting
patients with schizophrenia who have been lost to follow-
up may be another way to improve outcomes. Within the
VA system, researchers observed a higher rate of mortality
Cancer February 1, 2014

in patients with severe mental illness who were lost to
follow-up for at least 1 year. Reengagement in care by case
managers contributed to a 6-fold reduction in mortality,
particularly due to medical illness including cancer.74
Directions for Future Research
Given the prevalence of smoking in patients with schizo-
phrenia, research addressing smoking cessation in this pop-
ulation is critically needed. Understanding the barriers and
facilitators to cancer care in patients with schizophrenia is
necessary, incorporating the perspectives of patients, oncol-
ogists, PCPs, and mental health providers. These barriers
can be targeted in studies of novel models of care. In addi-
tion, it will be important to include individuals with schizo-
phrenia who are not engaged in mental health treatment;
targeting homeless adults may expand the population of
patients with schizophrenia currently studied.
Conclusions
Individuals with schizophrenia die significantly earlier
than the general population. Once diagnosed with cancer,
it appears that they are more likely to die of that cancer.
Building awareness of the health disparities experienced
by patients with schizophrenia and cancer is a critical first
step toward reducing excess mortality. Future research is
needed to determine the role of patient-based, provider-
based, and systems-based factors that influence specific
components of cancer care, ultimately impacting survival
and quality of life. At the same time, it will be important
to pilot novel models of care that integrate oncology and
psychiatric care to address the needs of patients with schiz-
ophrenia and cancer.
FUNDING SUPPORT
No specific funding was disclosed.
CONFLICT OF INTEREST DISCLOSURES
The authors made no disclosures.
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