Psychosomatics 49:538-539, November-December 2008
doi: 10.1176/appi.psy.49.6.538
© 2008 Academy of Psychosomatic Medicine
Panic as a Harbinger of Pancreatic Cancer
Benjamin T. Griffeth, M.D., and
Abhishek Mehra, M.D.
Received March 23, 2007; revised May 9, 2007; accepted May 18, 2007. From the Salem Veterans Affairs Medical Center, Univ. of Virginia–Roanoke/Salem Program, Univ. of Virginia, Dept. of Psychiatry, and VA College of Osteopathic Medicine. Send correspondence and reprint requests to Benjamin T. Griffeth, M.D., Salem VAMC, Mental Health, Code 116A7, 1970 Roanoke Blvd., Salem, VA 24153. e-mail: benjamin.griffeth{at}va.gov
© 2008 The Academy of Psychosomatic Medicine
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ABSTRACT
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BACKGROUND: Previous literature has discussed the diagnosis of cancer with psychiatric symptoms. There are noted associations made between pancreatic cancer and depression and anxiety symptoms both in literature and textbooks. METHOD: The authors discuss the case of a patient who presented with anxiety and panic attacks before his diagnosis of pancreatic cancer. CONCLUSION: There has been a previous association noted between depression and anxiety and pancreatic cancer; however, this work and another report have noted panic episodes preceding diagnosis, as well. These symptoms could prove to be an important marker for early detection.
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Case Report
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A 58-year-old white man presented to the Emergency Department (ED) from his primary-care clinic with anxiety and panic. The patient reported feeling nervous for the last 2 months, explaining that it was progressively getting worse. He stated that the episodes of anxiety would last for a few seconds to a minute, during which he would experience shortness of breath, a racing heartbeat, sweating, feeling nervous, tremulous, and, at times, nauseated. He did not have any particular stressors; the episodes were unprovoked; and he would worry about these attacks happening again.
He reported feeling depressed, with low energy, a decreased appetite, and a noticeable loss of weight over the last 2 months, totaling 12 pounds in 6 months. The patient lived alone and had been working as a driving instructor up until 2 months ago when he quit work because of anxiety while driving. There had been no previous history of depressive or anxiety symptoms. A combination of buspirone and citalopram had been prescribed by a primary-care physician only a few days before the patient’s presentation in the ED. The patient had presented to the ED on two previous occasions in the past 2 months, with similar complaints of anxiety and anorexia. He had a history of alcohol and cannabis abuse, although his last drink had been over 2 months ago, and he had last used marijuana before that. He denied use of any other illicit drugs or tobacco and drank decaffeinated beverages.
On presentation, the patient’s labs showed a chronic elevation of his SGPT/SGOT (95/55). He had received a scheduled CT scan of his abdomen the same morning of his presentation to the ED. The CT scan revealed a large pancreatic tail mass lesion involving the splenic hilum and the adjacent spleen. Multiple low-density areas in the liver, representing metastatic disease, were also noted, as well as low-density lesions in the spleen that represented likely infarcts. He was also noted to have a hypervascular right upper pole medial renal lesion compatible with renal-cell carcinoma. The overall impression was probable adenocarcinoma of the pancreas, with metastases in the liver, which was later confirmed on biopsy.
The patient was admitted for inpatient medical evaluation, where he rapidly developed gait instability. A CT of the head and MRI of the brain revealed a small lesion, interpreted as either infarction or further metastasis. He was seen by the oncology department, which recommended chemotherapy. The patient made a decision to have palliative care and died within 1 month.
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Discussion
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Depression and anxiety are more often associated with pancreatic malignancy than other gastrointestinal malignancies. Men with mental disorders are more likely to develop pancreatic cancer than those without psychiatric histories.1 One literature review suggests that 50% of patients present with depression and/or anxiety before the diagnosis of pancreatic cancer.2 Green and Austin1 also proposed that the psychopathology of pancreatic tumors may be due to tumor-induced neuroendocrine or acid/base changes. One previous case report discusses anxiety and panic attacks preceding the diagnosis of pancreatic tumor, as well as resolution of symptoms after resection of the mass.3 Another study noted psychiatric symptoms in 76% of a group of 46 patients with pancreatic neoplasm, and at least 50% had had psychiatric symptoms before any other symptoms.4 Symptom complexes that should alert physicians to possible underlying carcinoma are depression with weight loss greater than 20 pounds, no past or family history of depression, and an atypical age at onset.5
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Conclusion
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Our report, similar to a previous report,2 brings to light the preceding diagnosis of panic attacks, contrary to previous literature, which mentions the association of depression and anxiety with pancreatic cancer. Some studies have talked about the above psychiatric symptoms being a forerunner to the diagnosis of pancreatic cancer. Further research is needed to investigate this association between psychiatric symptoms and pancreatic cancer, especially preceding diagnosis. These symptoms could prove to be important marker for early diagnosis of pancreatic cancer in the future.
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REFERENCES
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- Green A, Austin C: Psychopathology of pancreatic cancer. Psychosomatics 1993; 34:208–221[Abstract/Free Full Text]
- Passik S, Roth A: Anxiety symptoms and panic attacks preceding pancreatic cancer diagnosis. Psychooncology 1999; 8:268–272[Medline]
- Fras I, Litin E, Bartholomew L: Mental symptoms as an aid in the early diagnosis of carcinoma of the pancreas. Gastroenterology 1968; 55:191–198
- Carney C, Jones L, Woolson R, et al: Relationship between depression and pancreatic cancer in the general population. Psychosom Med 2003; 65:884–888[Abstract/Free Full Text]
- Peterson L, Popkin M, Hall R: Psychiatric aspects of cancer. Psychosomatics 1981; 22:778–792
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