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Injuries common before, after cancer diagnosis
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Patients with cancer may have an increased risk for treatment-related and -unrelated injuries in the periods preceding and following their cancer diagnosis, according to the results of a registry study conducted in Sweden.
Injury is a leading cause of death in patients with cancer. Disease-related injuries remain common, and researchers have identified increases in non–disease-related injuries, self-harm, and accidental death.
“Previous studies have predominantly examined the risk [for] injuries, mostly fatal injuries, either after diagnosis of cancer or after treatment for cancer,” Qing Shen, PhD candidate in the department of epidemiology and biostatistics at Karolinska Institutet in Stockholm, and colleagues wrote. “It is, however, unknown whether the risk [for] injuries is also increased during the time period before the diagnosis. Evidence suggests that the diagnostic process of cancer entails severe emotional distress, regardless of the eventual result, and could therefore increase the risk [for] noniatrogenic injuries, intentional or unintentional.”
The researchers analyzed data from 740,114 patients (median age at diagnosis, 69 years; 51.7% men) diagnosed with a first cancer between 1991 and 2009.
Cancers in the study included prostate (n = 123,837), female breast (n = 101,458), colorectal (n = 84,527), nonmelanoma skin (n = 33,409), lymphatic or hematopoietic (n = 52,266), lung (n = 49,491), central nervous system (n = 21,199) and other (n = 220,087).
The researchers grouped cancers with an expectedly short survival interval, such as esophageal cancer, pancreatic cancer and liver cancer (n = 34,627). To account for lifestyle factors, they separately analyzed smoking-related cancers — including oral, nasopharyngeal, pancreatic, esophageal, lung, kidney, bladder and urinary tract cancers (n = 116,501) — as well as alcohol-related cancers, or oral, laryngeal, esophageal, biliary duct and liver cancers (n = 29,511).
Researchers used main discharge diagnoses to identify injuries as related to medical complications (iatrogenic) or unrelated to medical complications (noniatrogenic).
Regression models compared incidence rates during the diagnostic period — defined as the 16-week period before diagnosis and the 16-week period after diagnosis — and the prediagnostic period, which comprised the same 32-week period in the year preceding diagnosis.
Patients with cancer experienced 7,306 iatrogenic injuries during the diagnostic period, which correlated with an incidence rate of 0.6 per 1,000 person-months.
The risk for iatrogenic injuries was greater during the diagnostic period (incidence rate ratio [IRR] = 7; 95% CI, 6.6-7.4) than the prediagnostic period (IRR = 3.5; 95% CI, 3.3-3.8).
An increase in iatrogenic injuries appeared the 2 weeks preceding a cancer diagnosis and peaked 2 weeks following diagnosis (IRR = 48.6; 95% CI, 37.3-63.5).
Patients with CNS cancers had the largest increases in iatrogenic injuries during (IRR = 14.7; 95% CI, 10-2.16) and after (IRR = 7; 95% CI, 4.4-11.1) diagnosis. The smallest increases occurred in patients with nonmelanoma skin cancer (during: IRR = 2; 95% CI, 1.6-2.6; after: IRR = 1.4; 95% CI, 1.1-1.9).
Factors associated with increased risks included younger age, cohabitation, higher socioeconomic status or education level, and diagnosis during a later calendar period. Higher incidence rates and risks occurred in patients with pre-existing psychiatric conditions or previous injuries.
A total of 8,331 noniatrogenic injuries occurred during the diagnostic period, for an incidence rate of 0.69 per 1,000 person-months.
Similar risk increases occurred during the diagnosis (IRR = 1.9; 95% CI, 1.8-2) and post-diagnosis periods (IRR = 2; 95% CI, 1.9-2.1) and appeared similar across all major cancer types.
Increases in noniatrogenic injuries increased dramatically 4 weeks before a cancer diagnosis and peaked 2 weeks preceding diagnosis (IRR = 5.3; 95% CI, 4.6-6.1).
Older patients, patients from a lower socioeconomic status, and patients diagnosed during earlier calendar periods had increased risks for noniatrogenic injuries, as did patients with pre-existing psychiatric conditions or previous injuries.
The researchers acknowledged study limitations. The study only included data from patients who received inpatient care for injuries; thus, it does not address potential increases of a milder nature.
Further, the researchers acknowledged their inability to include social support factors, including doctor–patient communication.
“Although some injuries, especially iatrogenic injuries, are hard to prevent completely given the intensive diagnostics and treatment during the diagnostic period for cancer, our findings do clearly indicate the precise and critical time window around diagnosis for the prevention of iatrogenic and noniatrogenic injuries and the improvement of cancer care,” Shen and colleagues wrote. “Our findings comprehensively show for the first time the disease burden of medical complications from diagnostic investigations for cancer. More importantly, our results call for targeted prevention of intentional and unintentional injuries, not only after diagnosis but also during the diagnostic process and primary treatment process.”
These findings should encourage physicians to look beyond treatment-related risks for newly diagnosed patients with cancer, Holly G. Prigerson, PhD, professor of sociology in medicine at Weill Cornell Medicine and director of the Center for Research on End-of-Life Care, Susan G. Vaughan, MD, assistant professor of clinical psychiatry at Columbia College of Physicians and Surgeons, and Wendy G. Lichtenthal, PhD, assistant attending psychologist at Memorial Sloan Kettering Cancer Center, who wrote an accompanying editorial.
“Clinicians should warn patients who are worried about the possibility of cancer that poor concentration and preoccupation puts them at heightened risk for potentially serious mishaps making them ‘accident prone,’” Prigerson, Vaughan and Lichtenthal wrote. “Prevention efforts might include the recommendation that patients awaiting diagnostic results slow down and be deliberate and mindful of their surroundings. Arming patients with a toolkit of coping strategies to help them manage preoccupying levels of anxiety might also be helpful.”
The increase in noniatrogenic injuries in the periods immediately preceding and following a cancer diagnosis should further encourage oncologists to focus on the mental health of their patients, according to Prigerson and colleagues.
“[Oncologists] should join forces with mental health providers and nurses to screen and, when indicated, intervene with patients who are experiencing severe distress and psychological symptoms, as this heightens their risk of suicidal thoughts or actions,” Prigerson, Vaughan and Lichtenthal wrote. “Patients with cancer who lack a social support and a sense of self efficacy (that is, the belief in one’s ability to succeed in specific situations or accomplish a task) might feel isolated, helpless and desperate. Some might consider suicide preferable to death from cancer. Psychosocial interventions to help patients cope with their fears and regain a sense of control should be offered.” – by Cameron Kelsall
Disclosure: The researchers report no relevant financial disclosures. Prigerson, Vaughan and Lichtenthal report no relevant financial disclosures.
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