National Analysis: Suicide Is an Important Risk After Cancer Surgery
Key findings
- This study analyzed data from the National Cancer Institute on 1,811,397 patients who underwent cancer surgery to investigate the incidence and timing of suicide and the risk factors associated with suicide
- Overall, the incidence of suicide was 29% higher than expected in the general U.S. population, and the risk was also significantly higher for patients who received surgery for 10 of the 15 cancers evaluated
- About 50% of suicides were committed within the first three years after surgery, but the timing varied by site: cancer sites with lower five-year survival rates and higher standardized mortality ratios for suicide were associated with shorter time to suicide
- Patients who were male, white, divorced, or never married showed greater risk than other patients, and those who had surgery for cancer of the head and neck, bladder, esophagus or pancreas were at higher risk relative to the general U.S. population
- Surgical oncology practices should consider regular psychosocial distress screening of cancer patients during preoperative evaluation and postoperative recovery and increased psychosocial support during postoperative recovery
Up to 38% of patients who undergo cancer surgery develop major depressive symptoms afterward, suggesting suicide may be an important risk in this population. Many studies have assessed the incidence of suicide among cancer patients overall, but little is known about the risk in this subpopulation.
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Chi-Fu Jeffrey Yang, MD, a thoracic surgeon in the Division of Thoracic Surgery at Massachusetts General Hospital, Alexandra L. Potter, BS, a clinical research coordinator in the Division, and colleagues conducted a nationwide U.S. study of this question. They found the incidence of suicide was significantly higher, compared with the general U.S. population, among patients undergoing surgery for 10 of 15 cancers assessed.
In JAMA Oncology, the researchers also report that approximately 50% of these suicides were committed within the first three years after surgery.
Methods
The National Cancer Institute maintains the Surveillance, Epidemiology, and End Results (SEER) database, which provides individual-level data from population-based U.S. registries. SEER 18 includes 18 registries from 2000 to 2016, representing about 28% of the U.S. population.
The researchers identified 1,811,397 patients in SEER 18 who underwent surgery for one of 15 solid-organ cancers during the period captured and did not have multiple primary cancer diagnoses.
Incidence of Suicide
During a median follow-up of 4.6 years (range, 1.7–9.0 years), they found the following:
- 1,494 patients (0.08%) committed suicide, a rate of 14.5 suicides per 100,000 person-years
- After adjustment for demographics and year of death, the overall incidence of suicide was significantly higher than the incidence in the general U.S. population (standardized mortality ratio [SMR], 1.29; 95% CI, 1.23–1.36)
- Relative to the U.S. population, suicide risk was significantly higher among patients undergoing surgery for cancer of the larynx (SMR, 4.02), oral cavity and pharynx (2.43), esophagus (2.25), bladder (2.09), pancreas (2.08), lung (1.73), stomach (1.70), ovary (1.64), brain (1.61), and colon and rectum (1.28)
- Patients who underwent surgery for cancer with a five-year overall survival rate >80% (cancers of the corpus uterus, kidney, breast, or cervix) showed no significantly increased incidence of suicide compared with the general population
Timing of Suicide
About 3%, 21%, and 50% of suicides occurred within the first month, first year, and first three years after surgery, respectively. Cancer sites with lower five-year overall survival rates and higher SMRs for suicide were associated with shorter time to suicide after surgery.
Risk Factors
In multivariable analysis, patients who were male, white, divorced, or never married were at greater risk of suicide than other patients. Black and Asian patients were at lower risk than white patients, and older patients were at lower risk than younger adults.
Opportunities to Improve Care
Implementation of psychosocial distress screening in oncology has largely focused on medical oncology practices, not surgical practices. Yet many patients with cancer never see a medical oncologist.
Strategies to reduce postoperative suicide risk in cancer patients may start by focusing on higher-risk demographic subgroups and patients undergoing surgery for cancers of the head and neck, bladder, esophagus, and pancreas. These efforts should include regular psychosocial distress screening during preoperative evaluation and postoperative recovery and more intensive postoperative surveillance and support.
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