Better solutions needed to reduce suicides among patients with cancer

In light of these findings, the study authors suggest that better distress screening access and improved availability of psychosocial support for at least the most vulnerable high-risk patients with cancer, both before and after surgery, are urgently needed to reduce the risks of suicide in this patient population.

The study appears in JAMA Oncology (doi:10.1001/jamaoncol.2022.6549).

Study author Chi-Fu Jeffrey Yang, MD, a thoracic surgeon at Massachusetts General Hospital and an assistant professor of surgery at Harvard Medical School in Boston, says that previous studies reported that the risk of suicide is higher among patients diagnosed with cancer. “However, the risk of suicide among patients undergoing cancer operations was largely unknown.”

According to the researchers, the study had three goals: to determine how common suicide is among patients with cancer who have been treated with surgery, to discover when suicide is most likely relative to the time of cancer operations, and to identify clinical and demographic clues to help clinicians to recognize patients likely to commit suicide after surgery.

For the study, researchers culled cancer incidence, treatment, and cause-specific mortality data (including suicide data) between the years 2000 and 2016 from 18 population-based US registries of the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. Patients with more than one type of cancer were excluded, they wrote, “to avoid potential biases resulting from the

influence of past or future cancer diagnoses on suicide risk.”

They identified more than 1.8 million (1,811,397) adult patients with cancer who had surgery for one of 15 solid-organ cancers. Seventy-four percent of the subjects were women, and the median age was 62 years. The researchers calculated standardized mortality ratios (SMRs) to compare suicide rates of patients in the cohort with suicide rates in general in the United States.

In addition, they used both unadjusted analyses and multivariable Fine–Gray competing risk models to examine whether patients’ risk of suicide was associated with their year of death or with any clinical characteristics (cancer type and stage and cohort-level 5-year survivor for each cancer type) or demographic characteristics (gender, marital status, race, and age).

During a median follow-up period of 4.6 years (range, 1.7–9.0 years), the researchers found that 1494 patients (0.08%) committed suicide after undergoing surgery for cancer; this represents 14.5 suicides per 100 000 person-years, a rate much higher than the suicide rate in the general US population when it is adjusted by age, sex, race, and calendar year of death (SMR, 1.29). The 10 solid organ cancers examined in this study with suicide rates that are statistically significant relative to the general US population (adjusted by age, sex, race, and calendar year of death), in SMR result order, are as follows: larynx (SMR, 4.02), oral cavity/pharynx (SMR, 2.43), esophagus (SMR, 2.25), bladder (SMR, 2.09), pancreas (SMR, 2.08), lung (SMR, 1.73), stomach (SMR, 1.70), ovary (SMR, 1.64), brain (SMR, 1.61), and colon/rectum (SMR, 1.28). There was a statistically significant negative linear association between the SMR from suicide (standardized by age, sex, race, and year of death) and the 5-year survival for each of the 15 cancer types in this study.

The researchers discovered that approximately 3% of suicides were committed within the first month after cancer surgery, roughly 21% were in the first year, and 50% occurred less than 3 years after surgery. By comparison, approximately 50% of suicides committed after surgery for brain cancer occurred within the first year after surgery, whereas less than 6% of suicides after surgery for cervical cancer occurred within the first year. A comparison of the median time from surgery to suicide and 5-year survival by cancer type showed a statistically significant positive linear association, with earlier suicides found among patients with poor-prognosis cancer types.

Dr Yang says that because pre- and postoperative care for patients undergoing cancer operations often does not include care or support for mental health, there is a large gap when it comes to ensuring that patients have access to the appropriate mental health care at pivotal times. “This gap in care likely stems, in part, from our lack of knowledge regarding the burden of psychiatric morbidity specifically among this patient population,” he says. “For these reasons, I believe our study does break new ground as our findings illustrate that suicide is an important risk following cancer surgery and highlight the need to develop and implement distress screening programs in surgical oncology practices.”

Xuesong Han, PhD, scientific director of health services research with the American Cancer Society in Atlanta, Georgia, says that this study builds on previous studies on suicide among patients with cancer. Dr Han says that the one of this study’s most important new findings is that patients with deadlier cancers are more likely to have suicide deaths sooner after surgery in comparison with patients with cancers that have a better prognosis.

An accompanying editorial (doi:10.%201001/jamaoncol.2022.6373) written by Craig J. Bryan, PsyD, ABPP, and Kristen M. Carpenter, PhD, from the Department of Psychiatry and Behavioral Health, and Timothy M. Pawlik, MD, PhD, from the Department of Surgery at the James Comprehensive Cancer Center at Ohio State University in Columbus, notes that approximately 1 in 6 patients with cancer have a preexisting psychiatric condition. They state that this is critical to recognize because, in addition to suicide, psychiatric conditions can negatively contribute to other problems, “including increased perioperative complications, longer hospital stays, higher rates of readmission, and increased risk of postoperative suicidal ideation. Preoperative or perioperative treatment of psychiatric conditions may therefore lead to improved outcomes.”

Dr Han and her colleagues from the Health Services Research Group at the American Cancer Society also recently examined suicide risks among individuals diagnosed (regardless of treatment modality) with cancer from 43 US states across the same time period (doi:10.1001/jamanetworkopen.2022.51863) and found similar results regarding prognosis and suicide risk. She says that it is also important to emphasize that suicide prevention and interventions among the vulnerable cancer population require joint efforts by multiple stakeholders. “For example, researchers need to better understand the risk factors of suicide and evaluate the effectiveness of intervention programs; federal and state governments and employers need to ensure comprehensive health insurance coverage for psycho-oncologic, psychosocial, and palliative care; and clinicians and health care organizations need to develop and utilize appropriate clinical guidelines for suicide risk screening and to include tailored suicide prevention in both treatment plans and survivorship care plans.”

On a hopeful note, Dr Han points to an American Cancer Society study of trends in suicide rates between 1999 and 2018 (doi:10.1093/jnci/djaa183) that found cancer-related suicide had declined by an average of 2.8% per year while suicide rates in the overall US population had increased by an average of 1.7% annually. The American Cancer Society researchers attribute these trends to progress in psycho-oncology,palliative care, and hospice care during this period.