Regular suicide screening should be implemented for patients undergoing cancer surgery, say researchers, whose retrospective cohort study showed suicide cases were significantly higher in these patients than in the general US population.
Among patients undergoing surgery for the 15 deadliest cancers in the US from 2000 to 2016, the suicide rate was 14.5 per 100 000 person-years – a rate significantly higher compared with the general population after adjustments for age, sex, race and calendar year of death (standardised mortality ratio [SMR] 1.29, 95% CI 1.23-1.36), reported Dr Chi-Fu Jeffrey Yang of Massachusetts General Hospital in Boston, and colleagues.
About half of the suicides occurred within the first three years after surgery, while 3% and 21% occurred within the first month and first year, respectively, they noted in JAMA Oncology.
“These findings suggest the need to implement suicide screening among patients undergoing cancer operations, especially those whose demographic and tumour characteristics are associated with the highest suicide risk,” Yang and team wrote.
Specifically, compared with the general population, the incidence of suicide was statistically significantly higher among patients undergoing surgery for the following sites of cancer:
• Larynx: SMR 4.02 (95% CI 2.67-5.81)
• Oral cavity and pharynx: SMR 2.43 (95% CI 1.93-3.03)
• Oesophagus: SMR 2.25 (95% CI 1.43-3.38)
• Bladder: SMR 2.09 (95% CI 1.53-2.78)
• Pancreas: SMR 2.08 (95% CI 1.29-3.19)
• Lung: SMR 1.73 (95% CI 1.47-2.02)
• Stomach: SMR 1.70 (95% CI 1.22-2.31)
• Ovary: SMR 1.64 (95% CI 1.13-2.31)
• Brain: SMR 1.61 (95% CI 1.12-2.26)
• Colon and rectum: SMR 1.28 (95% CI 1.16-1.40)
Patients undergoing surgery for cancers with higher five-year overall survival rates had lower SMRs compared with patients undergoing surgery for cancers with lower five-year rates (slope -0.022, 95% CI -0.039 to -0.004, P=0.02). Of note, patients who underwent surgery for cancers with five-year overall survival rates greater than 80%, such as cancers of the corpus uterus, kidney, breast and cervix, showed no statistically significant increased incidence of suicide relative to the general population, the authors said.
The median time from surgery to suicide varied by cancer site and ranged from 11.5 months for patients with brain cancers to 78 months for those with cervical cancers.
Medpage Today reports that patients who were male, white and divorced or single were at greatest risk for suicide. According to Yang and colleagues, the combined effects of cancer site and patient characteristics increased suicide risk. For example, they reported that white men undergoing surgery for laryngeal cancer had a suicide rate (per 100 000 person-years) that was 63 times greater than that of black women undergoing surgery for breast cancer.
While major medical professional societies recommend that patients with cancer be screened for distress, adherence to these recommendations is low, the authors noted. Furthermore, these screening efforts are more likely to be implemented in medical oncology practices and not surgical oncology practices, they added.
“Thus, distress screening implemented in medical oncology practices may never reach patients who undergo cancer operations,” they wrote. “Further work is needed to develop and implement distress screening programmes in surgical oncology practices and to ensure that these adequately address the unique psychosocial needs of patients undergoing cancer surgery.”
In an editorial accompanying the study, Craig Bryan of the Ohio State University in Columbus and colleagues noted that one in six patients have pre-existing psychiatric conditions – conditions that are not only associated with suicide risk, but other outcomes as well, including perioperative complications, longer hospital stays, higher rates of readmission, and increased risk of postoperative suicidal ideation.
Thus, the results of this study not only emphasise the importance of screening patients with cancer for psychiatric conditions and suicide risk, but also “highlight the importance of ensuring access to evidence-based psychological and behavioural treatments both before and after cancer surgery”, they wrote.
For this study, Yang and colleagues used data from the Surveillance, Epidemiology, and End Results Programme database to examine the incidence and timing of suicide among patients undergoing surgery for the 15 deadliest cancers in the US from 2000 to 2016.
They included 1 811,397 patients (median age 62, 74.4% women). Of these patients, 1 494 (0.08%) died by suicide after undergoing surgery for cancer.
Study details
Incidence, Timing, and Factors Associated With Suicide Among Patients Undergoing Surgery for Cancer in the US
Alexandra Potter, Chinmay Haridas, Krista Neumann, Mathew Kiang, Zhi Ven Fong, Corinne Riddell, Harrison Pope, Chi-Fu Jeffrey Yang.
Published in JAMA Oncology on 12 January 2023
Key Points
Question What are the incidence, timing, and factors associated with suicide among patients undergoing cancer operations in the US?
Findings In this cohort study of 1 811 397 patients who underwent cancer surgery, the incidence of suicide, compared with the general US population, was statistically significantly higher among patients undergoing surgery for 10 of the 15 cancers assessed, with approximately 50% of suicides committed within the first three years after surgery. Patients who were male, white, and divorced or single had the greatest risk of suicide.
Meaning These findings suggest the need to implement suicide screening among patients undergoing cancer operations, especially patients whose demographic and tumour characteristics are associated with the highest suicide risk.
Abstract
Importance
The risk and timing of suicide among patients who undergo surgery for cancer remain largely unknown, and, to our knowledge, there are currently no organised programmes in place to implement regular suicide screening among this patient population.
Objective
To evaluate the incidence, timing, and factors associated with suicide among patients undergoing cancer operations.
Design, Setting, and Participants
This retrospective population-based cohort study used data from the Surveillance, Epidemiology, and End Results Program database to examine the incidence of suicide, compared with the general US population, and timing of suicide among patients undergoing surgery for the 15 deadliest cancers in the US from 2000 to 2016. A Fine-Gray competing risks regression model was used to identify factors associated with an increased risk of suicide among patients in the cohort. Data were analysed from September 2021 to January 2022.
Main Outcomes and Measures
Incidence, compared with the general US population, timing, and factors associated with suicide after surgery for cancer.
Results
From 2000 to 2016, 1 811 397 patients (74.4% female; median [IQR] age, 62.0 [52.0-72.0] years) met study inclusion criteria. Of these patients, 1494 (0.08%) committed suicide after undergoing surgery for cancer. The incidence of suicide, compared with the general US population, was statistically significantly higher among patients undergoing surgery for cancers of the larynx (standardised mortality ratio [SMR], 4.02; 95% CI, 2.67-5.81), oral cavity and pharynx (SMR, 2.43; 95% CI, 1.93-3.03), oesophagus (SMR, 2.25; 95% CI, 1.43-3.38), bladder (SMR, 2.09; 95% CI, 1.53-2.78), pancreas (SMR, 2.08; 95% CI, 1.29-3.19), lung (SMR, 1.73; 95% CI, 1.47-2.02), stomach (SMR, 1.70; 95% CI, 1.22-2.31), ovary (SMR, 1.64; 95% CI, 1.13-2.31), brain (SMR, 1.61; 95% CI, 1.12-2.26), and colon and rectum (SMR, 1.28; 95% CI, 1.16-1.40). Approximately 3%, 21%, and 50% of suicides were committed within the first month, first year, and first 3 years after surgery, respectively. Patients who were male, white, and divorced or single were at greatest risk of suicide.
Conclusions and Relevance
In this cohort study, the incidence of suicide among patients undergoing cancer operations was statistically significantly elevated compared with the general population, highlighting the need for programs to actively implement regular suicide screening among such patients, especially those whose demographic and tumour characteristics are associated with the highest suicide risk.
Medpage Today article – Cancer Surgery Linked to Higher Suicide Risk (Open access)
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