A Literature Review of Suicide in Cancer Patients

Linda Anguiano, MSN, RN; Deborah K. Mayer, PhD, RN, AOCN, FAAN; Mary Lynn Piven, PhD, PMHCNS-BC; Donald Rosenstein, MD


Cancer Nurs. 2012;35(4):E14-e26. 

In This Article


Cancer patients have a higher rate of suicide than the general population.[23,24] A number of factors place the cancer patient at higher risk for suicide including having prostate, lung, pancreatic, or head and neck cancer and being male, older, depressed, and recently (within the first year) diagnosed with cancer. Suicidality was also higher in adult survivors of childhood cancers.[25] In general, cancer patients who have significant physical, psychological, and social impairments may be at greater risk for suicide.[26]

Depression is a well-documented risk factor for suicide in cancer patients.[26] Depression and hopelessness are the strongest predictors of a desire for death in terminally ill cancer patients.[8] It has been established that depression in cancer patients adversely affects quality of life, including length of survival, adherence with care, and perception of pain. Depression is often undetected and underdiagnosed in cancer patients, and failure to treat is a major concern. Based on this research, use of the shorter screening tool (eg, the 3-item BHS, which includes [1] in the future, I expect to succeed in what concerns me the most; [2] all I can see ahead of me is unpleasantness rather than pleasantness; [3] it is very unlikely that I will get any real satisfaction in the future) to assess for depression and suicidal ideation in cancer patients is recommended. There is enough evidence to support use of this tool in current clinical practice. Alternatively, simply asking "are you depressed" may ease the use of suicide risk tools. Implementation of screening tools, however, will require clinical consultation with psychiatric experts, for instance, referral to a psychiatrist, a psychiatric-mental health nurse practitioner or clinical nurse specialist, social worker, psychologist, or other mental health professional.

Special populations were identified who may be at especially high risk of suicide. Men 65 years or older with lung, pancreatic, head and neck, or prostate cancer were identified in multiple studies to be at particularly high risk. Further studies, which focus on these patients, are needed in an effort to decrease the high rate of suicide in special oncology populations. However, current studies are limited by their focus on white populations and exclusion of minority groups. Future studies should focus on minority populations with cancer. Published population studies also failed to explore underlying mental illness, such as anxiety and major depression, and will likely bias results. The most glaring omission in current studies is the lack of screening tools to help prevent suicide in cancer populations. Further studies should be initiated to explore suicide prevention strategies in high-risk populations. Given these studies, one may speculate that cancer site does make an important difference in suicidality and therefore suggest a differential clinical approach to the identification and management of suicide.

Secondary prevention of suicide, defined as decreasing the likelihood of a suicide attempt in high-risk patients, is an important goal in the care of individuals with cancer.[25] Increased awareness among healthcare providers for cancer patients at greater risk may be the key to help decrease preventable deaths in this population. Early identification of and intervention with cancer patients at high risks of suicide should impact rates of death. A secondary benefit of early detection is to identify those risk factors, which are known to contribute to suicidality including depression, distress, and pain and to make appropriate interventions. These interventions include pharmacological and psychological interventions, follow-up care, and reduced access to lethal means.[27]

Implication for Future Research

Current research is limited, and prospective trials should be funded to further refine suicide risk using detection tools and to develop best practices for prevention. Special populations, such as older men with prostate cancer, should have interventions developed and tested to minimize suicide risk. Early identification with valid and reliable screening tools combined with these interventions should lead to decreased morbidity and mortality. Further research should also explore other factors such as marital status, socioeconomic factors, and ethnicity.

Implications for Healthcare Practice

Although a relatively rare event, healthcare providers should be aware that having a diagnosis of cancer increases the risk for suicide. More specifically, prostate, lung, pancreatic, and head and neck cancer; male sex; older adult; recent diagnosis; and depression have all been associated with an increased incidence of suicide. All of these variables except depression are easily identified by[28] the clinical approach. Incorporating the 3-item Beck assessment tool (16) into the admission flow sheet and simply asking the question "are you depressed" are simple, efficient methods to help identify the depressed cancer patient and alert the provider to either refer or treat these symptoms and arrange for follow-up. The tool should be in place on all intake follow-up questionnaires for all cancer patients as it may be hard to differentiate on specific cancer patients at risk. Educating providers of these increased risk factors especially among those with significant physical, psychological, and social impairments could be accomplished during annual continuing cancer updates.

Again, identifying and treating depression in the cancer patients could not only decrease the risk of suicide but also improve quality of life.