How to Work With a Patient Who Declines Cancer Treatment

Erik Bengtsen, MD, an assistant attending psychiatrist and assistant director of the Consultation-Liaison Psychiatry Training Program at Memorial Sloan Kettering Cancer Center, discussed the role of antidepressants in patients with a poor prognosis and how clinicians can respond when a patient with a favorable diagnosis declines treatment, as part of CancerNetwork’s® Ask Me Anything series.

Bengtsen said antidepressants can meaningfully improve quality of life, even when prognosis is poor. Depression drives negative rumination about pain and other physical symptoms and can cut patients off from friends, family, and pastimes; an antidepressant may provide enough of a buffer for patients to re-engage with what they enjoy. When a patient with a favorable diagnosis refuses treatment, he urged clinicians to start with curiosity and find the reason behind the decision. Sometimes the concern is a specific adverse effect, such as hair loss, that an alternative first-line option may avoid. Other times, a past trauma, such as watching a parent die during childhood, shapes the decision, and clinicians can explain how much supportive care and dose management have improved over recent decades.

Transcript:

CancerNetwork: Do antidepressants change quality of life in patients with a poor prognosis, or is it all psychosocial?¹

Bengtsen: I do think that antidepressants can improve quality of life. With depression, there’s a negative rumination about all the difficult aspects, whether it’s pain or other physical symptoms, and then an inability to connect with friends and family or enjoy other pastimes. If the antidepressant can provide a little bit of a buffer, we’re not so stuck in the negative ruminations, and we can do the things that we enjoy. Quality of life does improve.

CancerNetwork: How do you approach a situation in which a patient has a favorable diagnosis but declines treatment?²

Bengtsen: I would start by being curious and trying to find out the why behind this. Sometimes patients are very clear that they don’t want to lose their hair, and the oncologist can say, ‘We have these different options for first-line treatment, and this option doesn’t have that risk of losing your hair.’ So sometimes it’s driven by a specific [adverse] effect. Sometimes there’s a past trauma, for example, witnessing a parent at the end of life when they were a child or a teenager, and it was so difficult. Then we can often say that treatment doses have changed over the last few decades, and the [adverse] effects are often much more easily managed. We know much more about different medications to bring on board, or about dose reductions. It’s about trying to find out the why.

References

1. How do you think about patients who have a… [discussion thread]. Reddit, r/Psychiatry. Accessed October 13, 2026. https://tinyurl.com/3kmujc74

2. Have you experienced patients with favorable… [discussion thread]. Reddit, r/Oncology. Accessed October 13, 2026. https://tinyurl.com/w9eh58m9