Early collaboration with psycho-oncologists can make ‘meaningful difference’ in reducing suicide risk

Despite treatment advances and corresponding improvements in survival, suicide rates among those with cancer are alarmingly high — two times that of the general U.S. population.

Although the risk for suicide is associated with most cancer types, the risk is particularly elevated for those with head and neck, lung, and urological cancers. Suicide risk among those with cancer can stem from the effects of pain and cancer treatments and surgeries, as well as from the psychological and social impacts of the disease.

Sex, age and sociodemographic data are often used to help identify those in the general population at increased risk for suicide. However, data suggest that both men and women with cancer are at increased risk, and age and sociodemographic data have been less consistent in predicting suicide.

“When confronted with a cancer diagnosis, nearly one-third of patients consider suicide as an option to escape the possibility of death and anticipated suffering,” William Breitbart, MD, the Jimmie C. Holland chair in psychiatric oncology and chairman of the department of psychiatry and behavioral sciences at Memorial Sloan Kettering Cancer Center, told HemOnc Today. “Human beings are unique in that they engage in such existential questions as whether life is in fact worth living or not. [Suicide] is an option held in reserve in case they find themselves in an uncontrollable state of suffering.”

HemOnc Today spoke with psychologists, oncologists and mental health experts about the elevated risk for suicide among those with cancer, why certain malignancies are associated with higher risk, the difference between depression and suicidal ideations, and how clinicians can identify those in greatest need of additional psychosocial support.

Reasons for elevated risk

Suicide rates are doubled among patients with cancer when compared with the general population, and the rates among those with cancer are even higher when compared with patients with other chronic illnesses.

In a study published this year in Cancer, Saad and colleagues found that among more than 4.6 million patients with cancer, 1,585 committed suicide within the first year of diagnosis. These data equated to an excess risk of 2.51 per 10,000 person-years.

Researchers observed the highest observed-expected ratio for suicide among patients with diagnoses of pancreatic (8.01), lung (6.05), metastatic prostate (2.84) and colorectal (2.08) cancer. Higher ratios occurred for metastatic (5.63) than localized/regional disease (1.65).

Both men (2.66) and women (1.86) demonstrated higher observed-expected ratios.

Although a significant amount of effort has been directed toward treatment and finding a cure for cancer, experts say less attention has been given to mental health aspects of cancer care.

“Cancer, like any serious illness, is associated with increased risk for distress,” Stephanie C. Tung, MD, psychiatrist in the department of psychosocial oncology and palliative care at Dana-Farber Cancer Institute, said during an interview with HemOnc Today. “Cancer can increase the risk for depression and anxiety, which, in turn, can increase the risk for suicide. It is important to consider the physical symptoms of the cancer itself and side effects of treatment, and how best to address them.”

In a study published last year in Psycho-Oncology, Aboumrad and colleagues conducted root cause analyses (RCAs) of cancer-associated suicides to better understand system-level factors that may contribute to suicide among patients with cancer. The researchers additionally sought to highlight strategies to mitigate suicide risk.

The analysis included 2002 to 2017 data pooled from the Veterans Health Administration National Center for Patient Safety RCA database. Because these data were derived from VA hospitals, researchers noted the results may not be reflective of the general population.

Researchers identified 64 RCAs of cancer-associated suicide. All RCAs included older men and 44% of suicides occurred during treatment with palliative intent.

Common risk factors for suicide included depression (59%), medical comorbidities (59%) and pain (47%). The majority (67%) of suicides occurred within 7 days of a medical visit, with 41% occurring within the first 24 hours.

Source: Amanda Kowalski, courtesy of Massachusetts General Hospital Cancer Center.

“We know that the time from a cancer diagnosis matters,” Kelly E. Irwin, MD, assistant professor of psychiatry at Harvard Medical School and faculty psychiatrist at Massachusetts General Hospital Cancer Center, told HemOnc Today. “There is a markedly elevated risk [for suicide] within the first week of a cancer diagnosis and it remains elevated for the first year.”

Other risk factors include advanced-stage disease and uncontrolled symptoms, and the strongest predictor of a completed suicide is a previous suicide attempt, Irwin added.

“It is very important to collaborate with psychosocial clinicians to evaluate patients,” she said. “Overall, when someone receives a diagnosis that can be life-altering, it puts them into a vulnerable place and people react to that news differently. There is a subset of people who develop depression. There are key vulnerabilities — worry, pain, feeling less in control.”

Attempts to commit suicide also appear more common in the cancer population.

Results of an analysis presented at European Association of Urology Congress showed patients with cancer are nearly three times more likely to commit suicide than the general population, and that the proportion of attempted suicides resulting in a completed or successful suicide is higher among patients with cancer patients. The highest proportion was observed among patients with urological cancers.

Researchers additionally assessed suicidal intent among patients with cancer— defined as the ratio of successful suicides to the rate of attempted suicides, revealing a one-in-seven rate among those with prostate cancer compared with one in 25 among the general population.

“This is important as we know that people who attempt suicide are at higher risk for subsequently being successful in completing a suicide, and we have shown this intent to commit to be far higher in our cancer population, thus confirming a real need to address psychological issues early on in the management of these patients,” Mehran Afshar, PhD, consultant oncologist and clinical lead for acute oncology services at St. George’s Hospital in London, said in a press release.

Cancers with greatest risk

The malignancies associated with greatest risk for suicide are lung and head and neck cancers.

“No one really knows why suicide rates are higher for these malignancies, but there are theories,” 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 VA Portland Health Care System, said during an interview with HemOnc Today. “One of the biggest things is that prognoses among these cancer types appear to be poor — they are often found at advanced stage. Also, symptom burden for these cancers is high and they are associated with high rates of depression.”

Not only are those recently diagnosed with these cancers at risk, but so are survivors.

Survivorship comes at a cost for many patients, according to Nosayaba Osazuwa-Peters, BDS, PhD, MPH, assistant professor of otolaryngology at Saint Louis University School of Medicine and faculty member at Saint Louis University Cancer Center.

Osazuwa-Peters and colleagues conducted a study — published last year in Cancer — that compared the risk for suicide among a cohort of head and neck cancer survivors vs. survivors of other common cancer types.

Between 2010 and 2014, researchers identified 404 suicides among 151,167 survivors of head and neck cancer, yielding a rate of 63.4 suicides per 100,000 person-years. Conversely, 4,493 suicides were identified among 4,219,097 survivors of other cancer types, yielding an incidence rate of 23.6 suicides per 100,000 person-years.

“As a part of a study that we recently published, we captured the risk for suicide in the general U.S. population, which was 17.4 per 100,000 person-years vs. 63.4 per 100,000 person-years in the head and neck cancer population — nearly fourfold more,” Osazuwa-Peters told HemOnc Today. “For head and neck cancer, there is a lot of disfigurement — patients literally wear their cancer every day with scars from surgery. If someone has a facial disfiguration or they cannot taste food, or they cannot use their voice anymore, then there are significant quality-of-life issues.”

Results also showed a 27% increased risk for suicide among survivors of head and neck cancer from 2010 to 2014 compared with 2000 to 2004 (adjust RR = 1.27; 95% CI, 1.16-1.38).

“The suicide rate is definitely high in the head and neck population, but the rate is still high among all cancer survivors compared with the general U.S. population,” Osazuwa-Peters said. “This is why so many of us are talking about it.”

Many head and neck cancers are associated with maladaptive coping strategies, including alcohol and tobacco use, which may leave patients with fewer coping mechanisms following diagnosis. Further, facial disfigurement and related sequelae of treatment additionally leave patients with quality-of-life challenges, according to Breitbart.

In other malignancies, the difference in suicide risk is even more staggering.

According to study results presented at American Thoracic Society International Conference in 2017, patients with lung cancer had a 420% increased risk for suicide compared with the general population.

Rahouma and colleagues used the SEER database to identify 3.6 million patients. Researchers assessed the suicide death rate for all cancer types combined, as well as for lung, prostate, breast and colorectal cancers individually.

Results showed 6,661 suicides associated with cancer diagnoses during a 40-year period. Patients with any type of cancer had a 60% higher suicide rate than the general population.

When researchers assessed suicide risk among the four most common cancer types individually, lung cancer had the largest increase (standardized mortality ratio [SMR] = 4.2), followed by colorectal cancer (SMR = 1.4), breast cancer (SMR = 1.4) and prostate cancer (SMR = 1.2).

Median time to suicide was 7 months from diagnosis in lung cancer, 56 months in prostate cancer, 52 months in breast cancer and 37 months in colorectal cancer (P < .001).

Specifically for patients with lung cancer, incidence of suicide appeared higher among men (SMR = 8.8), Asians (SMR = 13.7), widowed patients (SMR = 11.6), patients aged 70 to 75 years (SMR = 12), patients with undifferentiated tumors (SMR = 8.6), patients with small cell lung carcinoma histology (SMR = 11.2), patients with metastatic disease (SMR = 13.9) and patients who refused surgery (SMR = 13).

“There is a broad range of cancers associated with high risk for suicide, and it is difficult to know the significance of these findings or to identify an underlying common potential cause for increased risk,” Breitbart said. “Some hypothesize that inflammation and the association of inflammation and depression may play a role.

“Clinically, I tend to focus more on concurrent risk factors for suicide — such as advanced disease, uncontrolled pain, lack of social support, clinical depression, comorbid psychiatric disorders (eg, substance use), delirium or cognitive disinhibition, and history of suicide attempts — as more useful predictors for risk than specific cancer diagnoses,” he added.

‘Depression is not normal’

Data suggest between 10% and 25% of patients with cancer develop clinical depression during some point in the cancer trajectory.

Further, depression is up to four times more common among patients with cancer than the general population.

“Sadness is normal. Fear is normal. Depression is not normal,” Irwin said. “Depression is a compilation of symptoms that affect cancer outcomes. The symptoms are treatable and are common among people with cancer.”

A diagnosis of depression is made when a patient exhibits a persistent and prominent depressed, sad or anhedonic mood that occurs almost all day, every day, for 2 or more weeks. In addition, depression encompasses a number of physical symptoms, including sleep disturbance, fatigue, appetite change, agitation or withdrawal, as well as a number of psychological symptoms, including worthlessness, guilt, hopelessness and suicidal ideation.

Suicidal ideation includes thoughts that range along a continuum from thinking about wanting to be dead to having a plan to end one’s life and intent to act on that plan.

“It is important to distinguish between thoughts about death and suicidal intent,” Irwin added. “I also ask, ‘What is keeping you from acting on those thoughts?’ It is important to know when to worry and when to engage psychosocial colleagues.”

Conventional wisdom is that depression screening alone is not enough to identify a person at risk for suicidal ideation, according to Breitbart.

“Suicidal ideation, without imminent intent, is quite common and may occur in up to 20% to 30% of patients with cancer,” he said. “Patients who have thoughts of suicide as some future option report that it allows them to cope better with the challenge at hand. [Patients with cancer] with pain or advanced disease are more likely to have suicidal ideations.”

A related construct, Breitbart added, is the “desire for hastened death.”

“About 17% of patients with advanced cancer have significant desire for hastened death,” he said. “There are a number of factors that predict suicide, suicidal ideation and desire for hastened death that are overlapping and present a framework for an approach to prevent suicide and treat the despair that leads to desire for hastened death, such as clinical depression, lack of social support, uncontrolled pain, hopelessness and a loss of meaning.”

In a study published in JAMA, Breitbart and colleagues found that untreated clinical depression accounted for nearly 45% of patients who reported an increased desire for death.

The researchers also evaluated the effects of treatment for clinical depression in patients with advanced cancer at high risk for suicide.

Results showed psychopharmacologic treatment resolved depression in the majority of patients, and 95% of patients with adequately treated depression no longer had an increased desire for death.

“The desire for death remitted when desire for death was associated with depression,” Breitbart said. “What we were left with was the need to explain high desire for hastened death in the remaining 55% of patients with advanced cancer. We found that uncontrolled pain, lack of social support and physical debilitation accounted for an additional 5% to 10% of patients.

“Surprisingly, hopelessness — independent of clinical depression — and loss of meaning accounted for an additional 30% of patients with an increased desire for death,” he added. “What oncology, psycho-oncology and palliative care practitioners lacked was an intervention to treat hopelessness and loss of meaning.”

Sullivan agreed there are factors other than depression at play in patients with suicidal ideations.

“Although patients with suicidal ideations may certainly be depressed, they are not necessarily always depressed,” he said. “When looking at people with suicidal ideations, only half are diagnosed with severe depression. These factors may include anxiety and PTSD, which are very different from depression.”

Fremonta Meyer, MD, assistant professor of psychiatry at Harvard Medical School and psychiatrist at Brigham and Women’s Hospital and Dana-Farber Cancer Institute, and colleagues found that one in five patients with cancer with high emotional stress developed PTSD within 6 months of a cancer diagnosis.

“This study essentially stemmed from our interest in cancer as a potential stressor in the sense that we constantly associate PTSD with other circumstances, such as rape, sexual abuse, accidents and natural disasters, but few studies have looked at cancer as a trigger for PTSD,” Meyer told HemOnc Today. “This is an incredibly high rate of PTSD and it underscores the fact that cancer can be traumatic in many ways. The diagnosis itself — especially if stage IV — cancer-related symptoms and side effects of cancer treatments can all be experienced as traumatic.”

Meyer urged oncologists to be aware of the risk for PTSD among their patients.

“Tell patients at certain points that you understand that the diagnosis and treatment can feel traumatic,” she said. “If they are experiencing any distress from this, refer them to a mental health clinician. Having a proactive approach instead of a reactive approach is most helpful.”

Universal screening

There is a rapid movement to screen for suicide in all patients with cancer across most major institutions.

“Screening all [patients with cancer] for suicide is now considered the standard of clinical practice,” Breitbart said. “At our institution, we screen all inpatients for suicidal ideation at every shift and have a program for establishing safety and referral for assessment and management. We are engaged in expanding suicide screening to all ambulatory patients, as well, and performing screening assessments at regular intervals — ideally with each clinical encounter.”

All NCI-designated cancer centers screen for distress, and they typically screen all inpatients and outpatients. Most distress screening tools inquire about suicidal ideation, and algorithms are in place for triage to mental health professionals.

There are a few different screening instruments for suicidal ideation, according to Tung.

“At Dana-Farber, screening is routinely conducted by nursing staff in the inpatient and outpatient settings,” she said. “There is a formalized questionnaire that inquires about thoughts of harming or killing oneself. However, since thoughts about suicide may emerge at different points in the disease trajectory, screening should be repeated by multiple providers throughout the course of cancer treatment.”

The Columbia Suicide Severity Rating Scale is considered the “gold standard” suicide screening tool. This brief scale is ideal because it assesses not only thoughts of suicide, but intent and actions, and, as such, is more specific in identifying patients who are at increased risk for suicide, according to Breitbart.

“The use of this scale in the VA and in multiple health care systems has dramatically lowered the rates of suicide where it is used,” he said. “The scale effectively addresses issues of pain and physical symptom control, social support, psychosocial counseling, and treatment of depression and delirium, and it provides assessment and treatment for despair caused by existential concerns such as loss of meaning, loss of dignity and hopelessness.”

However, according to Meyer, there is no evidence that suggests screening all patients for suicidal thoughts or ideations reduces the risk for suicide.

“But, there is evidence that targeted screening in potentially high-risk patients may reduce risk,” she said. “The best approach is to screen patients for depression and anxiety and, if they are found to be depressed or severely anxious, to ask additional questions about suicide.

“People may worry that asking about these things may give someone the idea that they should hurt themselves, but there is no evidence of this,” she added. “Simply asking about suicide does not put thoughts into patients’ heads to commit suicide.”

Potential interventions

In their study, Aboumrad and colleagues recommended actions to mitigate suicide risk, including the development of a distress checklist using information from National Comprehensive Cancer Network guidelines.

“Further studies should assess additional factors that may increase the risk of other adverse mental health outcomes in this population,” Aboumrad and colleagues wrote.

However, in the absence of a clear solution, experts with whom HemOnc Today spoke expressed the importance of palliative care in this setting.

Sullivan and colleagues found that palliative care reduced the risk for suicide among a cohort of more than 20,000 U.S. veterans with advanced-stage lung cancer.

In the study — published in Annals of the American Thoracic Society — researchers used the VA Central Cancer Registry to assess the impact of palliative care on suicide rates among 20,900 veterans diagnosed with stage IIIB or stage IV lung cancer.

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.

However, patients who received at least one palliative care visit after diagnosis were 81% less likely to die by suicide.

“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,” Sullivan said. “We need to do a better job identifying the physical and psychological symptoms and addressing those with our patients when treating their cancer. Earlier initiation and utilization of palliative care is needed because it could offer tremendous benefits to our patients.”

Breitbart agreed.

“Palliative care, as well as psycho-oncology services, should be introduced early on in the process of care and are vital to achieve the outcomes of prolonged survival and quality of life,” he said.

For instance, Meaning-Centered Psychotherapy (MCP) is a manualized brief, structured psychotherapeutic intervention that aims to help patients suffering with loss of meaning amid illness. Breitbart and colleagues at Memorial Sloan Kettering developed the intervention to help diminish feelings of cancer-associated despair by helping patients focus on the importance of creating, reconnecting with, experiencing and sustaining meaning in the face of illness. MCP has been demonstrated to be effective in randomized controlled trials published in Journal of Clinical Oncology, Breitbart said.

“Suicide and assisted suicide deal with suffering by eliminating the sufferer. As a medical profession and a society, we should rather strive toward eliminating the causes of suffering,” he said.

Despite growing awareness of the multifold benefits of palliative care, it is still underutilized, Tung said.

“It is a service that providers, patients and families should consider earlier on in the course of treatment,” Tung said. “In addition to increasing palliative care involvement, it is important to increase mental health and psychosocial care, as well. Partnerships between the oncology team, mental health services, social work and palliative care are critical. By reducing both physical and emotional distress and by treating them both systematically, we can reduce the risk for suicide in these patients.”

However, palliative care and psychiatry may not necessarily have the bandwidth to reach all patients with cancer, Irwin said.

“We need to think broadly. For example, our nurses are on the frontline with patients, and social workers are able to perform assessments,” Irwin said. “The collaborative care model has been shown to treat depression and increase access to psychosocial care by embedding a case manager onto an oncology team. A psychiatrist then consults with the case manager, which increases access to mental health care for patients with cancer.”

In addition to risk for suicide, it is important to raise attention to the fact that people with mental illness are dying prematurely of cancer because of inequities in cancer care, Irwin added.

“Asking our patients about their mental health history and involving mental health care early, ideally at the time of cancer diagnosis, can make a meaningful difference,” she said. “We need to raise awareness of this unmet need across disciplines.” – by Jennifer Southall

Click here to read the , “Should cancer clinical trial eligibility regarding mental illness be relaxed?”

References:

Aboumrad M, et al. Psycho-Oncology. 2018;doi:10.1002/pon.4815.

Afshar M, et al. Abstract 68. Presented at: European Association of Urology Congress; March 16-20, 2018; Copenhagen.

Breitbart W, et al. JAMA. 2000;284:2907-2911.

Chan CMH, et al. Cancer. 2017; doi:10.1002/cncr.30980.

Osazuwa-Peters N, et al. Cancer. 2018;doi:10.1002/cncr.31675.

Rahouma M, et al. Abstract 8321. Presented at: The American Thoracic Society International Conference; May 19-24, 2017; Washington, D.C.

Saad AM, et al. Cancer. 2019;doi:10.1002/cncr.31876.

Sullivan DR, et al. Ann Am Thorac Soc. 2018;doi:10.1513/AnnalsATS.201805-299RL.

For more information:

William Breitbart, MD, can be reached at Memorial Sloan Kettering Cancer Center, 641 Lexington Ave., 7th Floor, New York, NY 10022; email: breitbaw@mskcc.org.

Kelly E. Irwin, MD, can be reached at Massachusetts General Hospital Cancer Center, 55 Fruit St., Boston, MA 02114-2696; email: kirwin1@partners.org.

Fremonta Meyer, MD, can be reached at Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA 02215; email: fremonta_meyer@dfci.harvard.edu.

Nosayaba Osazuwa-Peters, BDS, PhD, MPH, can be reached at Saint Louis University School of Medicine, 1402 S. Grand Blvd., St. Louis, MO 63104; email: nosazuwa@slu.edu.

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.

Stephanie C. Tung, MD, can be reached at Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA 02215; email: stephanie_tung@dfci.harvard.edu.

Disclosures: Breitbart, Irwin, Meyer, Osazuwa-Peters, Sullivan and Tung report no relevant financial disclosures.