Denial and Avoidance in an Unusual Case of Death from Breast Cancer

Dear Editor: We recently encountered the case of a woman who died in an atypical way as a result of coping with a breast mass by denial and avoidance. The patient, aged 48 years and white, lived at home with her husband and 2 young children. For 4 to 6 weeks preceding her death, she isolated herself from her family in the basement, explaining that she had personal issues that she was handling alone. She continued to work at her job, where her coworkers noted that she had become withdrawn. She was later found dead in the basement, surrounded by blood-soaked, foulsmelling clothing and gauze. There was a penetrating injury of the right breast and chest wall. An autopsy revealed that the injury was from a large ulcerated breast carcinoma, which eroded the chest wall and opened a large artery. There was no evidence of metastasis, which is the most common cause of death from breast cancer (1,2). Death owing to hemorrhage occurs in only approximately 9% of breast cancer patients (1,2) and is usually a complication of progressive disease. Death from a localized and usually curable primary tumor such as this one is most unusual. We believe the patient's denial and avoidance of her disease were psychosocial factors leading to this atypical mechanism of death from breast cancer. Denial can impede a woman's willingness to undergo screening examination (3). A substantial number of women may not recognize a breast abnormality on their own, before it is found by screening (4,5). They may use avoidant coping mechanisms that prevent them from checking for potential disease (4). Women who experience denial prior to disease identification are also more likely to maintain that denial later in the course of disease (5). After a diagnosis of breast cancer, a woman may experience denial based on fear of changes in self-image or sexuality or on concerns about the effect of the disease on her relationships with her partner or children (6). Coping strategies after diagnosis tend to assume a proactive character (3,7,8), however, and may include such activities as acceptance, positive reframing, use of religion, expressing emotion, adopting a fighting spirit, seeking support, asserting self-control, or diverting energy to other matters (7-9). While proactive coping strategies may seem to caregivers to be more productive in dealing with a serious disease, denial is not inherently a poor coping strategy. It can provide relief of psychological distress during difficult periods of treatment (3,7) and may be associated with remaining recurrence-free or experiencing prolonged duration of survival in women with local disease (3,10,11). …

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