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Palliative care could reduce suicide risk among veterans with advanced lung cancer
Palliative care appeared to reduce the risk for suicide among a cohort of more than 20,000 U.S. veterans with advanced-stage lung cancer, according to study results published in Annals of the American Thoracic Society.
“Suicide is a significant national public health problem, especially among [people with lung cancer] and among veterans. As a result, manifestations of this impact — like social isolation, depression and anxiety — can go undiagnosed and untreated,” Donald Sullivan, MD, MA, MCR, assistant professor of medicine at Oregon Health & Science University School of Medicine and core investigator at Center to Improve Veteran Involvement in Care at Veterans Affairs Portland Health Care System, said in a press release.
Sullivan and colleagues assessed the impact of palliative care, which aims to relieve physical pain and address psychological issues, on suicide rates among 20,900 veterans diagnosed with stage IIIB or stage IV lung cancer included in the VA Central Cancer Registry.
Results showed 30 patients (0.14%) committed suicide, a rate more than five times greater than the average among all age- and sex-matched veterans who use VA health care.
Patients who received at least one palliative care visit after diagnoses were 81% less likely to die by suicide.
HemOnc Today spoke with Sullivan about why the risk for suicide among veterans with lung cancer is so great, how he and his colleagues conducted the study, the potential implications of the results, and ways clinicians can respond in their practice.
Question: Can you explain the prevalence of suicide among veterans with lung cancer?
Answer: Among patients with lung cancer in my study, it was about 210 per 100,000 person-years. In the general population, the suicide rate is about 13 per 100,000 person-years.
Q: Why is the risk so much higher in this subgroup?
A: Patients with lung cancer — compared with those who have other types of cancer — have high symptom burden, including both psychological and physical symptoms that impact their quality of life. Additionally, patients with advanced-stage lung cancer have a poor prognosis, which can spur feelings of hopelessness. There is a lot of stigma around a lung cancer diagnosis because, in most cases, it is a self-inflicted disease and patients with lung cancer tend to not share their diagnosis until the very end of life. They, therefore, do not have a lot of support.
Q: How did this study come about?
A: I am a health services outcomes researcher, and more recently I have been focusing on how to improve the quality of care among patients with lung cancer, especially in the VA. I had been looking at use of palliative care in our database and I found remarkable and unexpected results.
Q: How did you conduct the study?
A: These data — which come from a large, retrospective, observational study — were derived from a database of about 25,000 patients with advanced-stage lung cancer treated across the national VA health system from 2007 to 2013. This database was devised from a VA cancer registry, a well-validated source. I connected it with some other data registries, one of which is a suicide data repository within the VA.
Q: What did you find?
A: The incidence of suicide among patients with advanced-stage lung cancer is very high. Compared with the general U.S. population, and with other veterans within the VA who do not have advanced-stage lung cancer, the suicide rate is about 5.8 times higher among those with advanced lung cancer. The other main finding was the association between receipt of palliative care and a reduced risk for suicide. This has not been looked at before.
Q: What are the clinical implications of the findings?
A: It is not routine to screen patients diagnosed with lung cancer for suicidal ideation. Depressive symptoms are common among individuals with lung cancer, and we should be screening for them. However, suicide is not always linked to depression. If we just screen for depression, we are going to miss a subset of patients who are contemplating suicide. I think we will miss patients with screening for suicide ideation, but I think the realization that this is a significant problem is the first important step in how to devise solutions. Another major implication is the importance of palliative care, which is underutilized within this patient population. Realizing how important this is for advanced cancers and serious illness is key.
Q: What is the take-home message for clinicians?
A: I think we need to realize that patients with advanced disease are potentially at high risk for suicide, and we need to start thinking about ways to help these folks. We need to do a better job identifying the physical and psychological symptoms and addressing those with our patients when treating these diseases. Earlier initiation and utilization of palliative care is needed because it could offer tremendous benefit to our patients. – by Jennifer Southall
Reference:
Sullivan DR et al. Ann Am Thorac Soc. 2018;doi:10.1513/AnnalsATS.201805-299RL.
For more information:
Donald Sullivan, MD, MA, MCR, can be reached at Oregon Health & Science University School of Medicine, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098; email: sullivad@ohsu.edu
Disclosure: The study was funded by the NIH/NCI (K07CA190706) and the Veterans Affairs Portland Health Care System. Sullivan reports no relevant financial disclosures.