Patients who undergo surgery for cancer may be at increased risk for suicide, especially White men who are single or divorced and those with cancers of the head/neck, bladder, esophagus, and pancreas, new research shows.
Compared to the general population, the incidence of suicide was statistically significantly higher among patients who underwent surgery for 10 of the 15 deadliest solid-organ cancers evaluated.
Roughly half of suicides occurred during the 3 years after surgery ― a period in which patients are often still regularly following up with their healthcare team after their surgery, the researchers point out.
The study was published online January 12 in JAMA Oncology.
Dr Chi-Fu Jeffrey Yang
The findings suggest that suicide is “an important risk following cancer surgery and illustrate the need to improve access to support groups and to implement regular screening for distress during the postoperative period,” senior author Chi-Fu Jeffrey Yang, MD, Division of Thoracic Surgery, Massachusetts General Hospital, Boston, told Medscape Medical News.
“Several major medical professional societies recommend distress screening for all cancer patients. However, efforts to implement psychosocial distress screening in clinical practice have largely focused on the integration of psychosocial distress screening in medical oncology practices and not surgical oncology practices,” Yang told Medscape Medical News.
He noted that many patients with early-stage cancer who undergo cancer surgery receive their primary cancer care through their surgeon, and many do not ever see a medical oncologist. Consequently, distress screening implemented in medical oncology practices may never reach patients who undergo cancer operations.
“Thus, we believe that 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 said.
This study highlights the importance of screening cancer patients for psychiatric conditions and suicide risk and ensuring access to evidence-based psychological and behavioral treatments both before and after cancer surgery, say the authors of an accompanying editorial.
Craig Bryan, PsyD, and co-authors, with the Ohio State University, note that suicide-focused treatments such as brief cognitive-behavioral therapy are “demonstrably effective for preventing suicidal behavior among patients who have survived a suicide attempt, yet could be less effective in reducing suicidal behaviors among patients with terminal illness.”
They call for research aimed at understanding the similarities and differences between suicidal states, as classically defined, and end-of-life considerations among patients with terminal illness.
“Such research could advance the understanding of suicide and how to best prevent it across patient populations and to reveal clues for delivering compassionate and effective care for patients with cancer,” they conclude.
Suicide Among Cancer Patients Undergoing Surgery
Several studies have shown that the incidence of psychiatric morbidity among patients who undergo cancer surgery is high. It is estimated that 6% to 38% of patients develop major depressive symptoms after surgical treatment.
“However, the risk of suicide among patients undergoing cancer operations remains largely unknown,” Yang said.
To investigate, the researchers used the SEER database to identify roughly 1.8 million adults (74% women; median age, 62 years) who underwent cancer surgery in the US from 2000 to 2016.
During a median follow-up of 4.6 years, 1494 (0.08%) patients committed suicide following their cancer surgery ― a rate of 14.5 suicides per 100,000 person-years.
The incidence of suicide among cancer surgery patients overall was statistically significantly elevated (standardized mortality ratio [SMR], 1.29) compared with the incidence of suicide in the general US population, adjusted for age, sex, race, and calendar year of death.
The incidence of suicide was statistically significantly higher among patients who underwent surgery for cancers of the larynx (SMR, 4.02), oral cavity/pharynx (SMR, 2.43), esophagus (SMR, 2.25), bladder (SMR, 2.09), pancreas (SMR, 2.08), lung (SMR, 1.73), stomach (SMR, 1.70), ovary (SMR, 1.64), brain (SMR, 1.61), and colon/rectum (SMR, 1.28).
Roughly 3% of suicides were committed within the first month after cancer surgery, about 21% in the first year and roughly 50% in the first 3 years after surgery.
The median time from surgery to suicide varied by cancer site, ranging from 11.5 months for patients with brain tumors to 78.0 months for those with cervical cancers.
Cancer patients at greatest risk of committing suicide after surgery were male, White, and single or divorced.
The incidence of suicide tended to be lower among patients who had cancers associated with survival rates of more than 5 years. For cancers associated with survival rates above 80%, there was no statistically significant increase in suicide incidence compared with the general US population.
Notably, there was a statistically significant lower risk of suicide among patients who underwent adjuvant radiotherapy or chemotherapythan among patients who did not receive radiotherapy or chemotherapy.
This may be because the patients were more engaged in their cancer treatment and because of closer patient surveillance by the healthcare team during the perioperative period, the researchers say.
The study had no commercial funding. The authors have disclosed no relevant financial relationships. Bryan has received personal fees from Oui Therapeutics and Anduril LLC.
JAMA Oncol. Published online January 12, 2023. Abstract, Editorial
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