Suicide risk significantly higher among those who undergo surgery for cancer
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Adults who underwent surgery for most cancer types had a significantly higher incidence of suicide compared with the U.S. general population, results of a retrospective study in JAMA Oncology showed.
Approximately half of the suicides occurred within the first 3 years after surgery, with the highest risk among white men who were either single or divorced, the investigators noted.
Background
Previous studies have identified increased incidence of psychiatric morbidity among those undergoing surgery for cancer, according to Chi-Fu Jeffrey Yang, MD, a thoracic surgeon at Massachusetts General Hospital and assistant professor of surgery at Harvard Medical School.
“However, the risk [for] suicide among patients undergoing cancer operations remains largely unknown,” he told Healio. “Additionally, despite high rates of psychiatric morbidity in this population, there are currently no organized programs in place to implement regular screening for distress.”
Efforts to implement psychosocial distress screening in clinical practice have focused on the integration within medical oncology practices and not surgical oncology, Yang noted, adding that many patients with early-stage cancer who undergo surgery receive their primary cancer care through their surgeon and never see a medical oncologist.
“Distress screening implemented in medical oncology practices may never reach patients who undergo cancer operations,” he said.
Methodology
Yang and colleagues conducted a retrospective population-based cohort analysis to better understand the incidence, timing and factors associated with suicide among patients who underwent cancer surgery.
The researchers used data from the SEER database to determine the incidence and timing of suicide of U.S.-based patients who underwent surgery for the 15 deadliest solid-tumor cancers between 2000 and 2016.
Incidence of suicide compared with the general U.S. population served as the study’s primary outcome, with data expressed as standardized mortality ratios (SMRs).
Key findings
Yang and colleagues identified 1,811,387 adults (median age, 62 years; IQR, 52-72; 74.4% women) eligible for the analysis, of whom 1,498 (0.08%) committed suicide after undergoing surgery for a cancer-related indication in the U.S. during the study period. This represents a rate of 14.5 suicides per 100,000 person-years, a significantly higher incidence than that of the general U.S. population when adjusted for age, sex, race and calendar year of death (SMR = 1.29; 95% CI, 1.23-1.36).
The researchers found a significantly higher incidence of suicide vs. U.S. general population among adults who underwent 10 of the 15 cancer surgery types analyzed, including laryngeal (SMR = 4.02; 95% CI, 2.67-5.81), oral cavity and pharyngeal (SMR = 2.43; 95% CI, 1.93-3.03), esophageal (SMR = 2.25; 95% CI, 1.43-3.38), bladder (SMR = 2.09; 95% CI, 1.53-2.78), pancreatic (SMR = 2.08; 95% CI, 1.29-3.19), lung (SMR = 1.73; 95% CI, 1.47-2.02), gastric (SMR, 1.7; 95% CI, 1.22-2.31), ovarian (SMR, 1.64; 95% CI, 1.13-2.31), brain (SMR = 1.61; 95% CI, 1.12-2.26) and colorectal (SMR, 1.28; 95% CI, 1.16-1.4).
Further analysis showed that approximately 3% of suicides occurred within the first month of surgery, 21% within the first year and 50% within the first 3 years. Patients who underwent surgery for cancer types with lower 5-year survival rates committed suicide sooner after surgery compared with those who had diseases with higher 5-year survival rates (slope = 1.327; 95% CI, 0.734-1.92).
Multivariate analysis revealed significantly higher risk for suicide among patients who were male, white and divorced or never married.
Clinical implications
The finding that approximately of all suicides occur within 3 years of surgery for cancer reveal an opportunity to improve clinical care, according to Yang.
“This is a period in which patients are often still regularly following up with their health care team after their surgery and, thus, is an opportunity to potentially develop programs to screen for distress during this period,” he told Healio.
“Further work is needed to develop and implement distress screening programs in surgical oncology practices and to ensure that such programs adequately address the unique psychosocial needs of patients undergoing cancer operations,” Yang added.
The importance of screening patients with cancer for psychiatric conditions and suicide risk is underlined by the finding that patients who underwent surgery for cancers with lower 5-year survival rates died of suicide much sooner than those with longer 5-year survival rates, according to Craig J. Bryan, PsyD, ABPP, and colleagues from the department of psychiatry and behavioral health at The Ohio State University College of Medicine.
Further, patients who undergo cancer surgery should have access to evidence-based psychological and behavioral treatments, they added.
“The terminal patient wants to continue living but cannot. Suicidal patients want the reverse: they desire death and do not want to continue living because, to them, life is unbearably miserable and painful,” Bryan and colleagues wrote in an accompanying editorial. “For the suicidal patient, the choice to end one’s life more often involves the option of escaping their misery now or continuing to experience this misery indefinitely. This distinction in psychological states holds profound implications for treatment.”
References :
- Bryan CJ, et al. JAMA Oncol. 2023;doi:10.1001/jamaoncol.2022.6373.
- Potter AL, et al. JAMA Oncol. 2023;doi:10.1001/jamaoncol.2022.6549.
For more information :
Chi-Fu Jeffrey Yang, MD, can be reached at Massachusetts General Hospital, Division of Thoracic Surgery, Department of Surgery, 55 Fruit St., Boston, MA 02114; email: cjyang@mgh.harvard.edu.
Perspective
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Kathleen Ashton, PhD, ABPP
This study — which showed patients who underwent cancer surgery exhibited increased risk for suicide — is consistent with previous research and raises interesting clinical implications.
Past studies showed people with cancer — particularly male patients, those with specific cancers (eg, head and neck, lung, gastric or pancreatic) — and those with lower survival rates were higher risk for suicide than the general population.
This particular study highlights that current distress screening — which typically takes place in medical oncology clinics — likely misses at-risk surgical oncology patients.
Clinical implications include starting distress screening — including suicide risk screening — routinely during surgical oncology visits. Incorporating more integrated psychosocial professionals — such as psychologists, social workers and psychiatrists — throughout oncology clinics may improve mental health and suicide risk for people with cancer.
For example, at Cleveland Clinic, two psychologists are fully integrated into the breast surgery team and available for consultation and pre- and post-operative mental health care. People with breast cancer are screened routinely at every psychology appointment for depression, anxiety and suicidal ideation. Before the introduction of the Breast Psychology Clinic, patients typically were not screened until their medical oncology appointment. The Breast Psychology Clinic works closely with oncology social work and psychiatry to provide wrap-around care for patients with breast cancer before and after surgery, as well as during the entire cancer journey into survivorship. Similar models may help to provide better whole-person oncology care.
References:
Ashton K, et al. J Health Serv Psychol. 2022;doi:10.1007/s42843-022-00072-7.
Zaorsky NG, et al. Nat Commun. 2019;doi:10.1038/s41467-018-08170-1.
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