Beyond denial: A case report illustrating the complexity of disengagement in advanced cancer care

Denial in patients with advanced cancer is a common yet poorly understood phenomenon. This case report aims to illustrate the complexity of apparent denial in a psycho-oncology setting and to use it as a clinical anchor to review the concept of denial through multiple theoretical and practical lenses, highlighting key considerations for clinicians.

We present the case of a woman in her forties, originally from Africa, diagnosed with advanced metastatic gastric cancer. The case is examined through a narrative review of the existing literature on denial, encompassing psychological, psychiatric, neurocognitive, cultural, and systemic perspectives.

The patient demonstrated behaviors initially interpreted as denial by the treating service, including behaviors such as declining prognostic discussions, refusing to inform her family, and avoiding opioid analgesia, yet she explicitly acknowledged her diagnosis and its severity. Psycho-oncology consultation helped reframe her responses as coherent, value-driven choices rooted in her role as a mother and her cultural background, rather than as impaired insight or maladaptive coping. On the final day of her life, she accepted palliative care and consented to family notification, illustrating the fluid and evolving nature of apparent denial.

This case underscores the importance of individualized assessment and offering care before pathologizing patient disengagement. We discuss how palliative or psycho-oncology practitioners could distinguish adaptive coping from maladaptive denial, identify underlying psychiatric conditions, and screen for neurocognitive impairment if relevant. A multidisciplinary, empathic approach that respects patient autonomy is essential in navigating such complex encounters.