Increased Suicide Risk Among Patients Undergoing Cancer Surgery

Importance  

The risk and timing of suicide among patients undergoing cancer surgery remains largely unknown and, to our knowledge, there are currently no organized programs to implement regular suicide screening among this patient population.

Aim  

To evaluate the incidence, timing, and factors associated with suicide among patients undergoing cancer operations.

Design, scope and participants  

This population-based retrospective cohort study used data from the Surveillance, Epidemiology, and End Results Program database to examine the incidence of suicide, compared to the general US population. Top 15 Deadliest Cancers in the US .US between 2000 and 2016. A Fine-Gray competing risks regression model was used to identify factors associated with increased risk of suicide among patients in the cohort. Data was analyzed from September 2021 to January 2022.

Exhibitions  

Surgery for cancer.

Main results and measures 

Incidence, compared with the general US population, timing, and factors associated with suicide after cancer surgery.

Results 

Between 2000 and 2016, 1,811,397 patients (74.4% female; median [IQR] age, 62.0 [52.0-72.0] years) met study inclusion criteria. Of these patients, 1494 (0.08%) committed suicide after undergoing cancer surgery.

The incidence of suicide, compared with the general US population, was statistically significantly higher among patients undergoing surgery for laryngeal cancer (standardized mortality ratio [SMR], 4.02; 95% CI, 2.67-5.81), oral cavity and pharynx (SMR, 2.43; 95% CI, 1.93-3.03), esophagus (SMR, 2.25; 95% CI, 1.43-3.38), bladder (SMR, 2.09; 95% CI, 1.53-2.78), pancreas (SMR, 2.08; 95% CI, 1.29-3.19) , lung (SMR, 1.73; 95% CI, 1.47-2.02), stomach (SMR, 1.70; 95% CI, 1.22-2.31), ovary (SMR, 1 .64; 95% CI, 1.13-2.31), brain (SMR, 1.61; 95% CI, 1.12-2.26), and colon and rectum (SMR, 1.28; 95% CI, 1.12-2.31). 95%, 1.16-1.40).

Approximately 3%, 21%, and 50% of suicides were committed within the first month, the first year, and the first 3 years after surgery, respectively. Patients who were male, white, and divorced or single were at increased risk for suicide.

Conclusions and relevance  

In this cohort study, the incidence of suicide among patients undergoing cancer operations was statistically significantly elevated compared to the general population, highlighting the need for programs to actively implement regular suicide screening among these patients, especially those whose demographic and tumor characteristics are associated with the highest risk of suicide.

Comments

New research reveals high suicide rates among adults undergoing cancer surgery, with half of suicides occurring within the first three years after surgery.

Work led by a team of researchers at Massachusetts General Hospital (MGH), a founding member of Mass General Brigham, published in JAMA Oncology , highlights the need for regular distress screening and suicide assessment among these patients.

 “Several studies have now shown that the incidence of psychiatric morbidity among patients undergoing cancer operations is high: it is estimated that between 6% and 38% of patients develop symptoms of major depression after surgical treatment. However, the risk of suicide among patients undergoing cancer operations remains largely unknown,” says senior author Chi-Fu Jeffrey Yang, MD, a thoracic surgeon at MGH and assistant professor of surgery at the School of Medicine. Harvard Medicine. “In addition, there are currently no organized programs to implement regular distress screening among this patient population.”

“Many patients who undergo cancer operations, particularly those diagnosed with early-stage disease, achieve excellent long-term survival rates. Most patients undergo these operations with the intention that the surgery will give them the best possible prognosis,” says first author Alexandra Potter, a researcher at Mass General.

“However, cancer surgery can be stressful and patients may face long and complicated post-operative recoveries. “These factors, combined with the high rate of psychiatric morbidity among patients undergoing cancer operations, may contribute to an increased risk of suicide in this patient population.”

To better understand the incidence, timing, and factors associated with suicide among patients undergoing cancer operations, Yang and colleagues examined data from the Surveillance, Epidemiology, and End Results Program, which provides information on cancer statistics. in the US, for patients undergoing surgery for the 15 deadliest cancers.

Researchers found that between 2000 and 2016, suicides occurred in 1,494 of 1,811,397 patients (0.08%) who underwent cancer operations. The incidence of suicide, compared with the general US population, was significantly higher among patients who underwent surgery for cancer of the larynx, oral cavity and pharynx, esophagus, bladder, pancreas, lung, stomach, ovary, brain and colon and rectum.

Approximately 3%, 21%, and 50% of suicides were committed during the first month, the first year, and the first three years after surgery, respectively. Patients who were male, white, and divorced or single faced the highest risk of suicide.

“The incidence of suicide, compared with the general population, was significantly higher for patients who underwent surgery for 10 of the 15 cancers evaluated,” Yang says. "In addition, approximately half of the suicides occurred during the first 3 years after surgery, which is a time when many patients continue to follow up regularly with their healthcare team."

"Therefore, this period is an opportunity to potentially develop and implement programs to regularly screen patients for distress and ensure patients have access to appropriate support and treatment if needed."

Yang notes that several major medical professional societies recommend screening for psychosocial disorders for all cancer patients, regardless of their treatment, but efforts to implement screening into clinical practice have primarily focused on integrating screening into clinical practices. of medical oncology and not in surgical oncology practices.

“Many early-stage cancer patients who undergo cancer surgery receive their primary cancer care through their surgeon, and many never see a medical oncologist,” Yang says.

“Because distress screening implemented in medical oncology practices may never reach patients undergoing cancer operations, more work is needed to develop and implement distress screening programs in surgical oncology practices. ”.

The researchers are hopeful that their findings will stimulate efforts to develop effective strategies for suicide detection, evaluation and treatment for these patients.

An accompanying editorial highlights the importance of considering how many suicide cases in the study were terminal, meaning the patients’ deaths were expected to occur within six months. (In fact, patients who underwent surgery for cancers with lower 5-year survival rates had higher suicide rates.)

"Research aimed at understanding the similarities and differences between suicidal states, as classically defined, and end-of-life considerations among terminally ill patients deserves more attention," the editorial authors wrote. "Such research could advance the understanding of suicide and how to better prevent it in patient populations and reveal clues for providing compassionate and effective care to cancer patients."

Fragment of the editorial

Evidence-based strategies to reduce suicide mortality among cancer patients

Since 1999, the suicide rate in the US has increased more than 30%. Numerous studies have shown that suicide mortality is high among people with cancer, especially cancers with lower 5-year survival. In this article, Potter et al report that patients who underwent surgery for cancers with lower 5-year survival also died by suicide much earlier than patients with less fatal cancers, implying the importance of screening cancer patients for detect psychiatric conditions and suicide risk. Additionally, the data highlight the importance of ensuring access to evidence-based psychological and behavioral treatments both before and after oncologic surgery.

Approximately 1 in 6 patients has a pre-existing psychiatric condition. In addition to an association with suicide mortality, psychiatric conditions may negatively affect a variety of outcomes, including increased perioperative complications, longer hospital stays, higher readmission rates, and increased risk of postoperative suicidal ideation. Therefore, preoperative or perioperative treatment of psychiatric conditions may lead to better outcomes.