From the Editor

The big diagnosis. Even years after the fact and even in cases of good outcomes, so many still remember the exact moment when they were told that they had cancer. A patient once recalled with great detail the floor tiles in his doctor’s office (he couldn’t bear looking at his spouse or his doctor). He also remembered feeling so overwhelmed that suicide seemed like an option.

But what is the risk of suicide? In the first selection, Michael Heinrich (of the University of Regensburg) and his co-authors seek to answer that question, drawing on an impressive number of studies including more than 22 million patients. In a new paper for Nature Medicine, they report on a systematic review and meta-analysis; they found that “patients with cancer have an almost twofold increased risk of dying by suicide compared with the general population.” They write: “Despite immense progress in cancer therapy and prognosis in the past decades, suicide remains an important cause of death in patients with cancer.” We consider the paper and its clinical implications.

In the second selection, Dr. Natasha Z. Rabinowitz Steele (of Stanford University) considers her experiences in a New England Journal of Medicine paper. She writes about her cancer diagnosis and treatment, and the impact on her clinical work. She concludes: “Though all of our journeys will have beginnings and endings, our lives are what we choose to do with the precious, unpredictable, terrifying, and beautiful moments in between.”


Selection 1: Suicide risk and mortality among patients with cancer”

Michael Heinrich, Luisa Hofmann, Hansjörg Baurecht, et al.

Nature Medicine, 28 March 2022

The Global Burden of Disease Collaboration reported 24.6 million incident cancer cases for 2017, causing 233.5 disability-adjusted life-years and an increasing cancer incidence rate during the last 1.5 decades in 123 of 195 countries. For a patient, a diagnosis of cancer is one of the most dramatic and life-changing events, representing a severe psychosocial stressor. Patients with cancer may die by suicide for a number of reasons, including anxiety, pain, loss of perspectives and previous coping strategies, treatment-related adverse events and fatigue. Suicide is a global public health concern. More than 800,000 people die by suicide each year, with 20 suicidal attempts being carried out for each death by suicide.

Suicidal ideations among patients with cancer may arise through a patient’s will for self-autonomy and self-control, but they can also occur in the context of severe depressive symptoms. Whatever the cause, suicides are difficult to handle for next-of-kin and caregivers, who may be affected far beyond the loss of the patient.

The effectiveness of comprehensive psychological, psychiatric and psychotherapeutic management of patients with cancer is underscored by the estimation that every US$1.00 spent on psychotherapeutic interventions and interventions that strengthen linkages among different health-care providers saves US$2.50 in the cost of suicides.

Increased suicide rates in patients with cancer compared with the general population have been observed for decades in different populations around the globe. However, only few meta-analyses examined suicide risk among patients with cancer and those studies lacked a comprehensive literature search, generated incomplete findings regarding certain risk groups and/or analyzed only specific cancer entities, and/or presented only incidence rates without comparisons with the general population.

So begin a paper by Heinrich et al.

Here’s what they did:

  • “We carried out a systematic literature search of English language articles on completed suicides in patients with cancer published from inception to February 2021…”
  • They looked at several databases, including Ovid and MEDLINE.
  • “We assessed suicide mortality risk according to cancer prognosis, stage, time since diagnosis, gender, ethnicity, marital status, year of recruitment and geographic region.”
  • Various statistical analyses were done: “We used a random effects model, performed meta-regression meta-analysis and assessed heterogeneity and publication bias using I², funnel plots and Egger’s and Begg’s tests.”

Here’s what they found:

  • “We performed a systematic review including 62 studies and 46,952,813 patients… the meta-analysis was performed on 28 studies, involving 22,407,690 patients with cancer.”
  • Overall risk. “Our overall analysis revealed an 85% increased suicide mortality rate among patients with cancer compared with the general population (SMR = 1.85…), with considerable heterogeneity among studies.” See figure below.
  • Factors. “Risk was strongly related to cancer prognosis, cancer stage, time since diagnosis and geographic region.”
  • Prognosis. “Patients with cancers known to have a poor prognosis and patients with cancer during the initial year after diagnosis showed an approximately 3.5- and 3-fold increased suicide mortality, respectively, compared with the general population.”
  • Geography. “We also found marked geographic variation in suicide mortality, with cancer patients in the USA exhibiting the highest rate of suicide mortality and a 1.5-fold greater suicide mortality than patients with cancer in Europe.”

A few thoughts:

1. This is a good and important paper.

2. This also an impressive paper. The meta-analysis drew from the data of more than 22 million patients with cancer. Wow. The authors claim: “The present study is the largest and most comprehensive meta-analysis on suicide mortality in patients with cancer to date.”

3. A two-word summary of the big finding: prognosis mattered. Cancers with good prognoses (like nonmetastatic melanoma and testicular cancers) had the lowest suicide rates; in contrast, cancers with the worst prognoses (such as stomach and pancreatic cancers) had the highest suicide rates. 

The authors see various reasons for this: “The association between cancer prognosis and high suicide mortality may reflect causality by advanced tumor stage and grade resulting in more severe adverse effects on the quality of life of patients with cancer. The prospect of aggressive cancer therapy, hopelessness due to a life-changing or fatal cancer diagnosis or even existential angst could further increase suicidal thoughts and actions in patients with cancer. Suicide as an act of ultimate self-autonomy and control over one’s life may also account for some cases of suicide.”

4. Geography was also a factor. American cancer patients were much more likely to suicide than their European counterparts. The authors see various reasons, including “easy access to firearms.” They write: “In the USA in 2018, 24,432 of 48,344 suicides were carried out by firearms. This represents a tenfold increased rate compared with European countries, for example, Italy and German. In the USA, cancer patients show an increased odds ratio (OR) of 1.35… of dying by suicide by firearms compared with the general population.”

5. Like all studies, there are limitations. The authors note several, including with the data itself. “Due to limited availability of data from low-income countries, the present study is primarily generalizable to high-income countries. Creating a global literature base including low- and middle-income countries would help improve future analyses and allow a more comprehensive assessment of suicide among cancer patients.”

6. What is the effect of physician-assisted suicide (or medical assistance in dying, as we call it in Canada)? The authors didn’t have enough data to comment. (!)

7. What are the implications? In an accompanying commentary, Cristiane Decat Bergerot and Dr. Sumanta K. Pal (both of the City of Hope Comprehensive Cancer Center) write about the psychiatric implications of cancer, “Shining a light on the psychological burden of cancer.”

Cristiane Decat Bergerot

They see such findings as helping to “emphasize the huge importance of ongoing work to implement appropriate screening tools and improve access to supportive care, in order to recognize psychiatric disorders and curtail their consequences (such as suicidality). The US Food and Drug Administration has outlined core concepts for patient-reported outcomes, including the assessment of emotional well-being, which… must remain a crucial component of surveys in both clinical care settings and clinical trial settings. The consistent routine collection of such data will provide insight into the emotional well-being of patients and will enable provision of effective screening and care.”

8. The clinical take-away? The psychiatric needs of cancer patients can’t be forgotten in a journey that can involve specialists, subspecialists, imaging, surgery, and more. We often screen for depression – a major improvement over past years. We also need to screen for suicidal thoughts.

The full Nature Medicine paper can be found here:

Selection 2: “The Patient Resident”

Natasha Z. Rabinowitz Steele

The New England Journal of Medicine, 17 March 2022

I slide open the door and slip into my patient’s room. Mr. C. is a 64-year-old army veteran who presented several days ago with massive hemoptysis. I say those words aloud each morning on rounds, but they hardly describe him.

I learned intimate details about his body from his laboratory, imaging, and pathology reports. But I only came to know him through the hours at his bedside. The woman he loved was working in the artichoke fields and struggling to learn English. He was proud of his three sons, scattered around the country. After a career in combat, he was a God-fearing man, but he feared death most of all.

When I first examined him, I suspected he had cancer. He was cachectic, and I could feel the uneven contours of his organs beneath my fingers. Now, I’ve come to share the results of the biopsy.”

So begins an essay by Dr. Steele.

She talks about breaking the bad news to her patient. “We sit in silence. It’s a loud silence, full of racing fears of the unknown. It’s that moment when everything has changed for him: he has gone from before to after. I know this moment all too well.”

She also thinks of her own journey: “I look at my own hands – hands that a year prior first held my newborn daughter. Hands that, soon after, clutched my phone as I read my own radiology report: ‘Mediastinal lymphadenopathy consistent with lymphoma. Bilateral pleural effusions.’ I remember the room started to spin but I felt paralyzed; then paralysis gave way to sobs. ‘I don’t want to leave her,’ I repeated to my husband over and over.”

She notes her transformation: “Just 2 weeks into my internship, the disparate identities of physician, mother, and cancer patient had collided inside me. I didn’t know who I should be at any given moment. I had expected to learn medicine by observing and caring for patients; instead, I learned about chemotherapeutics, antiemetics, and granulocyte colony-stimulating factors firsthand. At a time when I was just beginning a life of healing by day and parenting by night, I suddenly became a patient in my own hospital, at the mercy of my mercurial biology.”

“After I left the hospital, time slowed. For years, I had been in a rush – working to get into medical school; withstanding the pressure to survive classes; transitioning to wards while trying to maintain my marriage and start a family; prepping for board exams and residency interviews. Now, the cadence of my life followed a series of 2-week cycles centered around chemotherapy. My hair fell out in fistfuls, my postpartum skin hung off my aching bones, my breast milk vanished.”

She details the long months of treatment and recovery, of PET scans and blood tests, of the “full-time” job of being sick. She regains her health and returns to the wards as a resident.

She writes about the change in her approach to clinical work. “I stopped rushing through my ward work. When patients spoke, I slowed to listen. I pledged to be their ally in a journey through the unknown, a journey I share. Slowly, my identities as cancer patient, doctor, and parent began to complement one another, their sum greater than the parts.”

A few thoughts:

1. This is a beautiful essay.

2. There is a profound honesty in her writing: “I was cancer-free. But being cured was only the start of healing.”

3. The image at the beginning of this Reading was Robert Pope’s “Radiation.” Pope painted and drew about his experience as a cancer patient, the disease that ultimately killed the Nova Scotia artist. You can read more about his life, legacy, and foundation, here:

The full NEJM paper can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.