From the Editor
When I worked closely with cancer patients, we would often speak of that moment – the moment they were diagnosed, when they officially became cancer patients. Many recalled their first emotions: the disbelief, the shock, the anger. A few could even tell me sparkling details, like the way the doctor looked at them or what she was wearing. And, for all, that moment had been life altering.
That moment is followed by challenges, and for some, depression and even suicide.
What is the risk of suicide after the cancer diagnosis? In this week’s Reading, we look at a new JAMA Psychiatry paper. Drawing on English data, and involving 4.7 million people, Public Health England’s Katherine Henson and her co-authors look at cancer and suicide. They find: “Despite low absolute numbers, the elevated risk of suicide in patients with certain cancers is a concern, representing potentially preventable deaths.”
Big diagnosis, big risk?
In this Reading, we consider the paper on this important topic, as well as an editorial.
Cancer and Suicide
“Risk of Suicide After Cancer Diagnosis in England”
Katherine E. Henson, Rachael Brock, James Charnock, Bethany Wickramasinghe, Olivia Will, Alexandra Pitman
JAMA Psychiatry, January 2019
A diagnosis of cancer can cause substantial psychological distress. Patients may fear death; pain; adverse effects of treatment, such as disfigurement or loss of function; or alterations in their family and community roles. This distress may have a role in the development of suicide ideation: previous evidence from systematic reviews has shown an increased risk of suicide among patients with cancer.
In the United Kingdom, the prevalence of patients with a cancer diagnosis is growing, driven by increased survival, improved cancer treatments, and expanding cancer screening programs. Despite political and financial prioritization of diagnostic and therapeutic cancer services and public health campaigns aimed at facilitating earlier diagnosis of cancer, there are substantial historical resource constraints for mental health services. In addition, acute care hospitals and mental health services remain disconnected.
Although the absolute risk of suicide may be low compared with the risks for other causes of death in patients with cancer, these deaths are potentially preventable. They are also a proxy marker of substantial psychological distress in patients with cancer. In 2015, the Cancer Taskforce report highlighted that better management of depression could improve patient outcomes, affecting quality of life as well as adherence to treatment, thereby having an influence on survival. To target psychological screening and support for the patients in greatest psychological distress and at risk of suicide, we need to understand variation in risk of suicide by patient group as defined by, for example, age, sex, and cancer type.
To our knowledge, this study is the first national population-level analysis of suicide among patients with cancer in England. Using longitudinal data from the National Cancer Registration and Analysis Service, linked to Office for National Statistics death certification data, we examined the risk of suicide in patients with a cancer diagnosis compared with that of the general population. We further analyzed the risk in terms of cancer type and stage, time since diagnosis, and sociodemographic factors.
Katherine E. Henson
So begins a new paper by Henson et al.
Here’s what they did:
- The authors drew on data from Public Health England’s national cancer registration database. They included cancer patients from January 1, 1995, to December 31, 2015, who were 18 to 99 years of age at the time of the diagnosis.
- Cause of death was determined by using data from the Office of National Statistics.
- They looked at a variety of characteristics, including gender, type of cancer, and age.
- Various statistical analyses were done, including multivariable Poisson regression models.
Here’s what they found:
- A total of 4 722 099 individuals received a diagnosis of cancer during the study period.
- A total of 2 491 patients (1 719 men and 772 women) with cancer were recorded to have died by suicide, or 0.08% of all deaths.
- Gender. People who suicided were more male than female (69.01%). Gender variation, though, depended on the cancer type.
- Cancer type. “The highest SMR (standardized mortality ratios) and AER (absolute excess risks) were observed among patients with mesothelioma, with a 4.51-fold risk compared with the general population, which corresponded to 4.20 extra deaths per 10 000 person-years. This risk was followed by pancreatic (SMR, 3.89…), esophageal (SMR, 2.65…), lung (SMR, 2.57…), and stomach (SMR, 2.20…) cancers.”
- Timing. “The SMR was greatest in the first 6 months after cancer diagnosis (SMR, 2.74…), but remained elevated throughout the first 3 years (2-year SMR, 1.14…). The risk decreased over time (P < .001). This association remained after multivariable adjustment.” See figures below.
- Age. “The cumulative risk of suicide mortality was greatest for patients with mesothelioma, stomach, and lung cancer. By age 80 years, the cumulative risk was 1.60% for patients with mesothelioma.”
The authors write:
In our nationwide population-based study of 4 722 099 patients, we found that being diagnosed with cancer in England confers a 20% increased risk of suicide compared with the general population, equivalent to 0.08% of all deaths among patients with cancer or 2491 potentially preventable deaths over this period. Our study identified specific factors characterizing those at higher risk, which will assist in the needs-based psychological assessment of these groups. Cancer types associated with particularly elevated risks are mesothelioma, pancreatic, lung, esophageal, and stomach cancers. These tend to be characterized by poor prognosis. We identified the first 6 months after a cancer diagnosis to be the period of highest risk. Although suicide is hard to predict, these findings indicate that all patients, and particularly those with the cancer types at highest risk, require improved psychological support and screening for suicidality in the immediate aftermath of cancer diagnosis.
A few thoughts:
- This is a good study.
- Using a national database, this study includes 4.7 million people. Wow.
- The authors do a great service by looking at certain characteristics, such as the type of cancer.
- Clearly, the risk isn’t equally distributed across all cancers or equally throughout the follow-up period. From clinical and policy perspectives, interventions should be targeted accordingly. The authors comment on the finding that the first 6 months are of particularly high risk: “This early phase is clearly a critical period. The mechanisms of suicide among patients with cancer are likely to be heterogeneous, involving factors beyond diagnosable psychiatric disorder. The shock of a cancer diagnosis and the losses inherent to it may be processed as a psychological threat. In some cases this shock can give rise to psychological symptoms diagnosable as depression or anxiety. The prevalence of major depression in patients with cancers is 15%, exceeding the 2% reported for the general population.”
- There is much to like in this study, including the long follow-up period, up to 22 years. There are limitations, of course. The authors note, for example: “One limitation of the study is that it was not possible, due to current data availability, to adjust for preexisting psychiatric disorders or other potential confounders, such as alcohol or drug misuse diagnostic information.”
- The paper is accompanied by an editorial by Harvard University’s Matthew K. Nock, Franchesca Ramirez, and Osiris Rankin, “Advancing Our Understanding of the Who, When, and Why of Suicide Risk.”
Matthew K. Nock
Nock has been profiled in The New York Times as “the suicide detective.” Despite the sleuthing, much remains mysterious to him – and us. They open their editorial by discussing the “perplexing” nature of suicide.
Still, they put this paper in a larger context:
This study adds to a growing body of research that has identified segments of the population at elevated risk for STBs [suicidal thoughts and behaviors], and in doing so, it also highlights important lacunae in our understanding. Some of the most consistent findings in studies of STBs are that 90% to 95% of those who die by suicide have a diagnosable mental disorder before their death and that the presence of certain types of physical conditions, such as multiple sclerosis and cancer (as in the study by Henson et al), also are associated with increased risk. The fact that most people who die by suicide have one of these conditions has led some to suggest that the conditions offer an explanation of the suicide. However, the explanatory power of such an association is limited, given that most patients with mental and physical conditions never even consider suicide.
You can find the paper here: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2714593.
The image at the opening of this Reading is Robert Pope’s “Sparrow.” Pope, a Nova Scotia native, painted and drew about many subjects, including his experience as a cancer patient. You can read more about his life, legacy, and foundation, here: https://robertpopefoundation.com/news-events/.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.