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Case history

image A 75-year-old woman with oestrogen receptor-negative, HER2-negative metastatic breast cancer was referred for consideration of palliative treatment. Her metastatic disease (multiple pulmonary nodules only) had recently been diagnosed on routine surgical follow-up, 6 months after radical mastectomy and axillary node clearance. She attended the clinic appointment with her daughter and son-in-law, who said she had moderate Alzheimer's dementia (Mini-Mental State Examination 14/30), but maintained a good level of function. She was independent in basic activities of daily living (ADL), but not in instrumental ADL.

Three months later, a re-staging CT scan revealed evidence of progressive disease. A decision was made to offer the patient systemic therapy with oral capecitabine.


How would you assess this patient's capacity to consent to treatment? What is the definition of 'capacity', and is there a test to determine mental capacity?

What would your management be if this patient were assessed to have no capacity with regards to consenting to the specific decision about her options for treatment?

What is the evidence base for her treatment options?

What other considerations should be made when offering this patient systemic anticancer therapy?


Cancer is an age-related disease, and the prevalence of dementia also increases with age. With a global ageing population, by 2030, 70% of all cancers will occur in older people, and 63 million people worldwide will have dementia.1 Dementia is a progressive neurodegenerative condition characterized by impairment in memory and at least one other cognitive domain (aphasia, apraxia, agnosia or disturbances in executive functioning), as well as a compromised ability to perform daily functions.2 Patients with dementia who are diagnosed with cancer pose a unique challenge, owing to the potential for impaired decision-making capacity, poor communication and difficulties following medication regimens.

How would you assess this patient's capacity to consent to treatment? What is the definition of 'capacity', and is there a test to determine mental capacity?

Decision-making 'capacity' refers to an individual's ability to make decisions or to take actions that influence his or her life. Capacity has to be assumed unless proven it is lacking. It is decision-specific (e.g. the patient may have capacity to decide which flavour ice cream she would prefer, but may lack capacity with regards to consenting for treatment), and a person is allowed to make an 'unwise' decision provided they have the capacity to do so. Progressive dementia may interfere with decision-making abilities involved in any aspect of life. An assessment of cognitive function may alert the clinician to the possibility of impaired decision-making capacity but cannot be used to assume incapacity. As there is no uniformity in the illness progression, specific capacities may be lost at different periods during the course of each person's disease; therefore it is important to assess each patient individually and regularly.

In 2007, the Mental Capacity Act (MCA) 2005 came ...

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