Chronic schizophrenia with aggravation of psychiatric symptoms after cancer surgery: a case report and mini literature review
Case Report | Psychiatric, Psychological, Social, and Spiritual Issues in Palliative Medicine and Palliative Care

Chronic schizophrenia with aggravation of psychiatric symptoms after cancer surgery: a case report and mini literature review

Junji Yamaguchi ORCID logo, Ryoichi Sadahiro ORCID logo, Saho Wada, Eri Nishikawa, Tatsuto Terada, Rika Nakahara, Hiromichi Matsuoka ORCID logo

Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan

Contributions: (I) Conception and design: J Yamaguchi; (II) Administrative support: J Yamaguchi, R Sadahiro, H Matsuoka; (III) Provision of study materials or patients: J Yamaguchi; (IV) Collection and assembly of data: J Yamaguchi; (V) Data analysis and interpretation: J Yamaguchi; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Junji Yamaguchi, MD, CP. Department of Psycho-Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo City, Tokyo, Japan. Email: juyamag2@ncc.go.jp.

Background: Patients with cancer and comorbid psychiatric disorders, including schizophrenia, may experience aggravation of psychiatric symptoms during cancer treatment. Oncology hospitals without dedicated psychiatric wards sometimes face challenges in managing cases with severe psychiatric symptoms. Concerns exist that the worsening of psychiatric symptoms may lead to the interruption of cancer treatment.

Case Description: A woman in her 60s had chronic schizophrenia, with an estimated onset in her 20s. She had long been prescribed quetiapine (150 mg/day, oral), haloperidol (0.75 mg/day, oral), nitrazepam (10 mg/day, oral), and paroxetine (20 mg/day, oral). At X years, she was diagnosed with ovarian cancer and underwent surgery following discontinuation of the psychotropics. On day 2 after hospitalization, she became confused, hallucinatory, and delusional with severe agitation. Although initially stabilized, the patient exhibited worsening psychiatric symptoms again on day 7. Ultimately, the patient was mentally stabilized with adjusted doses of oral quetiapine (250 mg/day) and haloperidol (1.5 mg/day, oral) and was discharged on day 16. Thanks to the intervention, cancer treatment continued uninterrupted.

Conclusions: Patients with comorbid schizophrenia and cancer may present severe psychiatric symptoms in the cancer perioperative period, even if schizophrenia is in a chronic phase. Postoperative delirium, withdrawal delirium, and exacerbation of schizophrenia were speculated to be the possible contributing factors in this case. When patients with cancer also have schizophrenia, oncologists and liaison psychiatrists need to carefully monitor their mental status to prevent interruptions in cancer treatment.

Keywords: Cancer; chronic schizophrenia; interruption of cancer treatment; postoperative and withdrawal delirium; case report

Submitted Aug 19, 2025. Accepted for publication Jan 27, 2026. Published online Feb 26, 2026.

doi: 10.21037/apm-25-91

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Key findings

• Patients with comorbid schizophrenia and cancer may present severe psychiatric symptoms in the cancer perioperative period, leading to the possible interruption of cancer treatment.

• Postoperative delirium, withdrawal delirium, and exacerbation of schizophrenia, respectively, were regarded as the possible contributing factors to the aggravation of mental status in the cancer perioperative period.

What is known and what is new?

• Patients with cancer and coexisting psychiatric disorders, including schizophrenia, are pointed out to be a high-risk group for discontinuation of cancer treatment due to the potential instability of their mental health.

• In this paper, the timing and reasons for the worsening of psychiatric symptoms in patients with schizophrenia in the cancer perioperative period, which have not been sufficiently reported, are described.

What is the implication, and what should change now?

• Appropriate evaluation of the patient’s condition and adjustment to psychotropics can stabilize mental status and prevent the interruption of cancer treatment.

• In the cancer perioperative period, when patients with cancer also have schizophrenia, oncologists and liaison psychiatrists need to more carefully monitor and assess their mental status so as not to cause an interruption in cancer treatment.

Introduction

Patients with cancer and coexisting psychiatric disorders, including schizophrenia, are considered a high-risk group for discontinuation of cancer treatment due to the potential instability of their mental health (1). The deviation from standard cancer treatment has been associated with increased cancer mortality and decreased quality of life in patients with cancer and psychiatric disorders (2). In addition, the psychological burden on the patient’s family generally has been observed to increase in cases of cancer and psychiatric disorders (3). Moreover, the suicide rate has been reported to increase with comorbid cancer in all psychiatric disorders (4). Therefore, in patients with cancer and psychiatric disorders, including schizophrenia, the stabilization of the patient’s psychiatric symptoms is essential for improving cancer outcomes, enhancing quality of life, supporting the mental well-being of the patient’s family, and preventing suicide.

Based on the above, the clinical analysis of the clinical course of a patient with both cancer and schizophrenia is important for understanding how the patient’s mental status deteriorates and how the cancer treatment may be interrupted. Surprisingly, however, based on our literature review, very few previous reports specifically describe the timing and reasons for worsening of the psychiatric symptoms in patients with schizophrenia during cancer treatment.

Here, we report a case of chronic schizophrenia with aggravation of psychiatric symptoms after cancer surgery. In this case, a concern was that the patient’s cancer treatment might be interrupted due to worsening psychiatric symptoms. However, appropriate evaluation of the patient’s condition and adjustment to psychotropics stabilized her mental status and prevented the interruption of cancer treatment. We present this article in accordance with the CARE reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-25-91/rc).

Case presentation

A woman in her 60s presented with schizophrenia. She had two siblings, both of whom were diagnosed with schizophrenia and had passed away. She had a history of bronchial asthma, which was currently in remission. Although she had no history of illegal drug use, the patient began experiencing hallucinations and delusions in her 20s and was hospitalized several times for repeated overdoses of psychotropics. The patient was prescribed quetiapine (150 mg/day, oral), haloperidol (0.75 mg/day, oral), nitrazepam (10 mg/day, oral), and paroxetine (20 mg/day, oral) by her psychiatrist. Her mental condition was relatively stable, with monthly clinic visits and regular medication. During the last 10 years, she had not been admitted to a psychiatric hospital, although transient psychotic symptoms, such as auditory hallucinations or delusions, were occasionally observed.

At X years, she was diagnosed with left ovarian cancer (stage IA, adenocarcinoma) with left-sided abdominal pain and was referred to our hospital for surgery. From her first visit to our hospital, she exhibited vague delusions of persecution, disorganized thinking, and negative symptoms, leading to a diagnosis of chronic schizophrenia by the first author, a trained psychiatrist. However, no apparent cognitive decline was observed, and the patient’s understanding of ovarian cancer was adequate. The patient desired surgery after receiving an explanation from the gynecologist.

On the day of admission, she exhibited anxiety and became easily upset by trivial matters due to the change in the environment. We performed a liaison intervention, providing supportive listening to alleviate the patient’s anxiety. Consequently, the patient became calm.

On day 1, the extended radical hysterectomy was completed as planned. The procedure lasted 5 hours and 28 minutes, with a blood loss of 651 mL. No unexpected complications occurred during the operation. In this case, propofol (total 1,132.42 mg) and remifentanil (total 5.05 mg) were used as intraoperative anesthetics. After the operation, we considered the possibility of anesthetic-induced delirium. However, reports indicate that the incidence of postoperative delirium with either propofol or remifentanil is comparable to or even lower than that with other anesthetics (5-9). Furthermore, the surgery did not involve any unexpected new intraoperative events. Bleeding was within the anticipated range, requiring no transfusion, and there was no excessive use of anesthetics. Based on these factors, anesthetic-induced delirium was less likely to occur. Additionally, the surgical course did not present a situation in which postoperative delirium was actively anticipated.

We used the Nursing Delirium Screening Scale (NuDESC) to assess acute psychiatric symptoms over time following the surgery (10). This is because NuDESC is more convenient than other assessment scales while remaining effective for evaluating postoperative delirium (10,11).

All psychotropics originally used were temporarily discontinued for 2 days following surgery, with regular intravenous administration of haloperidol (5 mg/day) and hydroxyzine (25 mg/day) as alternatives. On the night of day 1, disorientation and insomnia were noted, which were presumed to be mild postoperative delirium. We selected haloperidol and hydroxyzine because both agents can be administered intravenously, minimizing patient burden, and prior reports indicate that their combination does not worsen delirium (12,13). In particular, Hirayama et al. noted that the combination of hydroxyzine and haloperidol did not exacerbate postoperative delirium in patients with cancer (12), suggesting it could be an effective alternative to oral psychotropics in this case.

However, on day 2, the patient suddenly became very agitated, presenting with symptoms of auditory hallucinations, paranoia directed toward her gynecologist, and propagation of thoughts. With the rise of the NuDESC score (Table 1), autonomic nervous system symptoms, such as sweating and tachycardia, were also noted (Figure 1). Laboratory findings on day 2 revealed an elevated inflammatory response, and exacerbation of postoperative delirium was suspected (Table 2). In addition, the possibility of withdrawal delirium due to the discontinuation of paroxetine and nitrazepam by the operation was also considered, given the onset of autonomic nervous symptoms. Because the patient refused oral medication, we attempted to place a nasogastric tube. However, the patient was delirious and pulled it out immediately after placement, making continued use difficult. We then initiated a blonanserin transdermal patch (40 mg/day), which gradually made the patient calm. Paroxetine and nitrazepam were not resumed due to the possibility of worsening postoperative delirium and strong refusal of oral intake. However, laboratory findings on day 4 revealed elevated creatine kinase levels, suggesting the possible side effects of blonanserin. The blonanserin transdermal patch was then discontinued, and quetiapine (150 mg/day, oral) was resumed, as it was deemed appropriate due to the absence of apparent side effects in the past. Due to the effect of the blonanserin transdermal patch, the patient gradually began to comply with oral medication. Then the patient’s mental status was again stabilized.

Table 1

Changes in NuDESC scores after hospitalization

Days after admission NuDESC score (range: 0–10)
0 0
1 0
2 5
3 10
4 4
5 3
6 0
7 0
8 10
9 6
10 5
11 1
12 0

From the 12th day of hospitalization until discharge, NuDESC remained at 0. NuDESC, The Nursing Delirium Screening Scale.

Figure 1 Clinical course of the patient. CK, creatine kinase.

Table 2

Laboratory findings of the patient after admission

Parameters Days after admission
0 2 4 5 7 9 14
WBC (/μL) 5,200 10,500 7,100 6,400 5,500 5,900 5,500
RBC (104/μL) 457 427 360 355 374 360 365
PLAT (104/μL) 28.2 24.6 25.9 28.4 35.1 39.7 42.6
Total protein (g/dL) 7.2 4.5 4.8 – – 5.5 5.4
TBil (mg/dL) 0.7 0.8 0.8 – 0.6 0.6 0.5
BUN (mg/dL) 14 12 6 5 5 6 6
eGFR (mL/min/1.73 m2) 54 53 75 84 81 67 63
Cre (mg/dL) 0.82 0.84 0.61 0.55 0.57 0.68 0.71
AST (U/L) 19 18 74 60 71 91 18
ALT (U/L) 11 8 27 31 56 97 34
γ-GTP (U/L) 16 10 11 – 19 26 25
Na (nmol/L) 136 138 136 142 140 144 144
K (nmol/L) 4.3 4.8 3.7 3.4 3.2 3.1 4
CK (U/L) – 220 1355 700 169 90 26
CRP (mg/dL) 0.11 7.19 5.72 3.03 0.76 0.4 0.08

Peak inflammatory response was observed on day 2. CK elevation was observed on Day 4, but decreased to the normal range with adequate infusion. ALT, alanine aminotransferase; AST, aspartate aminotransferase; BUN, blood urea nitrogen; CK, creatine kinase; Cre, creatinine; CRP, C-reactive protein; eGFR, estimated glomerular filtration rate; K, potassium; Na, sodium; PLAT, platelet; RBC, red blood cell; TBil, total bilirubin; WBC, white blood cell; γ-GTP, γ-glutamyltransferase.

However, around day 7, the paranoia and hallucinations worsened again, and the patient attempted to leave the hospital due to auditory hallucinations. The NuDESC score has risen again. Laboratory findings improved, and no autonomic symptoms were present to indicate withdrawal. The patient had already passed through a period of postoperative delirium and withdrawal delirium and was presumed to have a worsening of schizophrenia. The relatively unstable mental status of the patient at the time of admission was also presumed to suggest an exacerbation of schizophrenia. Her psychiatrist informed us that haloperidol had been most effective when she was admitted to a psychiatric hospital in the past; therefore, we resumed the treatment, and the symptoms improved. She was ultimately stabilized with quetiapine (250 mg/day, oral) and haloperidol (1.5 mg/day, oral) and was discharged on day 16. After treatment, the patient confirmed that she was mentally stable and denied any recurrence of hallucinations or delusions. Additionally, as a result of adjustments to her psychotropics, no side effects from the medication were observed. The patient continued to visit her psychiatrist and remained mentally stable with quetiapine and haloperidol with no change in the dosage. Owing to the above-mentioned intervention, she was able to continue her subsequent cancer treatment, including chemotherapy, without interruption.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

According to Irwin et al., discontinuation of psychiatric consultations, nonadherence to antipsychotics, and a history of psychiatric hospitalization after cancer diagnosis are associated with the interruption in cancer treatment among patients with schizophrenia and breast cancer (14). These facts suggest that worsening psychiatric symptoms are associated with the discontinuation of cancer treatment. Conversely, in the present case, none of the factors mentioned were applicable, but a deterioration in mental status occurred with the risk of interruption of cancer treatment. The patient’s psychiatric symptoms were severe enough to warrant consideration of transfer to a psychiatric hospital, and the interruption of cancer treatment was likely due to the worsening psychiatric symptoms. However, after appropriate adjustment for antipsychotics, her mental status improved, and no interruption of cancer treatment occurred.

In this case, postoperative delirium, withdrawal delirium, and worsening schizophrenia were respectively speculated to have contributed to the aggravation in mental status. Particularly, the psychiatric symptoms on day 2 and autonomic nervous symptoms, such as sweating and tachycardia, suggested that withdrawal delirium may have occurred following the discontinuation of paroxetine and nitrazepam, in addition to postoperative delirium. We have previously reported the first case of benzodiazepine withdrawal delirium in the cancer perioperative period in the field of psycho-oncology (15). In this case as well, although the interruption was due to surgery and unavoidable, withdrawal delirium is presumed to have occurred. Besides, we attribute the worsening of psychiatric symptoms from day 7 to the worsening of schizophrenia because the patient was passing through a period of withdrawal symptoms, had a good postoperative recovery, and had no problems with laboratory findings. These facts indicate that appropriate assessment of mental status and adjustment to psychotropics are important for stabilizing psychiatric symptoms during cancer treatment.

Patients comorbid with schizophrenia and cancer are more difficult to treat than other cancer patients because of the possible aggravation of psychiatric symptoms during cancer treatment. In patients with schizophrenia and cancer, cancer screening rates are significantly lower (16), resulting in a 50% increase in mortality rates (17-21). Furthermore, an increase has been observed in the morbidity rate of pancreatic, esophageal, and breast cancers, respectively (22). Patient factors, including poor lifestyle, negative attitudes toward cancer treatment, and comorbidities, as well as medical prejudice and stigma, have been identified as causative factors of increased mortality in patients comorbid with schizophrenia and cancer (16). Patients with schizophrenia are more likely to engage in problematic health behaviors, such as smoking, and are at an elevated risk of having advanced stages of cancer due to less frequent cancer screening (20). Furthermore, patients with schizophrenia are less likely to continue chemotherapy and radiation therapy, experience significant postoperative complications, and receive reduced rates of palliative care (20). In this case, too, the patient’s hospitalization was compromised by psychiatric symptoms and the possibility of leaving the hospital, which could have interrupted proper postoperative management and chemotherapy.

Additionally, we speculate that the limited number of hospitals capable of treating both psychiatric problems and cancer simultaneously, as seen in this case, may be a hidden factor contributing to the discontinuation of cancer treatment in such patients. As for this, Funayama et al. reported that the total number of psychiatric units in general hospitals, which can cope with both psychiatric disorders and physical health problems, declined by 15.4% from 2002 to 2022 in Japan (23). They also suggest the challenging circumstances involved in sustaining psychiatric units within general hospitals (23). When psychiatric symptoms worsen, oncology hospitals without psychiatric wards struggle to cope with such severe symptoms, while psychiatric hospitals face challenges in managing serious physical complications such as cancer. At this point, close collaboration between oncologists and liaison psychiatrists, even before psychiatric symptoms worsen, remains essential to prevent further mental health deterioration.

A limitation of this study is that we could not definitively determine whether the worsening of psychiatric symptoms was mainly caused by schizophrenia, postoperative delirium, or withdrawal delirium. However, based on the laboratory findings, timing of symptom onset, and the combination of psychiatric and autonomic nervous symptoms, all factors appear to have contributed to the deterioration of the patient’s mental status. We think that more clinical case reports are needed to clarify the reasons underlying treatment discontinuation in patients with schizophrenia and cancer.

Conclusions

In the cancer perioperative period, when patients with cancer also have schizophrenia, oncologists and liaison psychiatrists should carefully monitor the patient’s mental status to prevent interruption of cancer treatment. This study may offer important insights into the prevention of cancer treatment interruptions and contribute to improving the quality of life for patients with schizophrenia.

Acknowledgments

The authors sincerely thank the patient for her participation in this study.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-25-91/rc

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-25-91/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-25-91/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Yamaguchi J, Sadahiro R, Wada S, Nishikawa E, Terada T, Nakahara R, Matsuoka H. Chronic schizophrenia with aggravation of psychiatric symptoms after cancer surgery: a case report and mini literature review. Ann Palliat Med 2026;15(2):27. doi: 10.21037/apm-25-91

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