Rural residents with head and neck cancer at significantly higher risk for suicide
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Patients with head and neck cancer who reside in rural areas appeared five times more likely to die by suicide than the general population, according to study results published in JAMA Otolaryngology-Head & Neck Surgery.
Suicide prevention strategies should account for the association between rural health and increased risk for suicide among these patients, researchers noted.
“Cancer survivorship comes at a cost,” Nosayaba Osazuwa-Peters, PhD, BDS, MPH, CHES, member of Duke Cancer Institute and assistant professor in head and neck surgery and communication sciences and population health sciences at Duke University School of Medicine, told Healio. “It is great for us to continue to make strides in keeping our patients healthy and alive, but it is not enough to only keep them alive years after treatment. There is a huge psychosocial burden that comes along with keeping cancer survivors alive.”
Psychosocial outcomes represent a huge burden of survivorship among patients with head and neck cancer, according to Osazuwa-Peters.
“Once I realized that, I decided to investigate this further,” he said. “The current study is a continuation of my general body of work investigating the drivers of adverse psychosocial outcomes among [patients with head and neck cancer].”
Osazuwa-Peters and colleagues sought to assess whether the risk for suicide among these patients differed according to rural, urban or metropolitan residence status.
The cross-sectional study included data from the SEER database on 134,510 patients (mean age, 57.7 years; 75.2% men) diagnosed with head and neck cancer between 2000 and 2016. Researchers assessed residence using 2013 Rural Urban Continuum Codes, and compared suicide risk by residence status using Fine-Gray proportional hazards regression models.
Overall, 86.6% of the study population resided in metropolitan areas, 11.7% resided in urban areas and 1.7% resided in rural areas.
Researchers identified 405 suicides. Researchers calculated a suicide mortality rate of 126.7 per 100,000 person-years among those who lived in rural counties, compared with rates of 59.2 among those residing in metropolitan counties and 64 among those in urban counties.
Results showed a significantly higher risk for suicide among patients with head and neck cancer who resided in rural (standardized mortality ratio [SMR] = 5.47; 95% CI, 3.06-9.02), urban (SMR = 2.84; 95% CI, 2.13-3.71) and metropolitan areas (SMR = 2.78; 95% CI, 2.49-3.09) compared with the general population.
Fine-Gray competing risk analyses showed residents of urban (subdistribution HR [sHR] = 0.52; 95% CI, 0.29-0.94) and metropolitan counties (sHR = 0.55; 95% CI, 0.32-0.94) had significantly lower risk for suicide than rural residents.
The difference in suicide incidence between rural residents in the study and the general population surprised researchers, Osazuwa-Peters told Healio.
“It was already known that [patients with head and neck cancer] have a higher suicide rate than the general population — this study confirmed that — but it also showed the suicide rate was five times higher among patients residing in rural areas compared with the general U.S. population. This was shocking,” he said.
Researchers plan to use empirical data to identify factors that may be associated with elevated suicide risk among rural residents.
“We hypothesize that the cancer care provided in rural areas is not uniform across the board,” Osazuwa-Peters said. “Many comprehensive cancer centers are in urban and metropolitan areas, and not every [patient with cancer] who resides in a rural area is able to travel repeatedly to the city to receive care. In addition, patients residing in rural areas may not have access to psychosocial care and/or may have greater access to lethal means.”
For these reasons, it is important to integrate mainstream psychosocial services for patients with cancer, Osazuwa-Peters added.
“We should not wait for our patients to exhibit signs of suicide before we act. Instead, psychosocial services should be embedded into mainstream cancer care proactively. This takes away the stigma and the lack of patients wanting to have a conversation about it in the first place.”
For more information:
Nosayaba Osazuwa-Peters, PhD, PDS, MPH, CHES, can be reached at Duke University School of Medicine, 40 Duke Medicine Circle, Duke South Yellow Zone 4080, DUMC 3805, Durham, NC 27710; email: nosa.peters@duke.edu.
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Osazuwa-Peters N, et al. JAMA Otolaryngol Head Neck Surg. 2021;doi:10.1001/jamaoto.2021.1728.
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