Childhood Cancer Survivors Live With Increased Suicide Risk

Neil Osterweil

October 30, 2013

In the year after a cancer diagnosis, adolescents and young adults are at more than twice the risk of attempting or committing suicide, according to new research.

A study conducted in Sweden assessed the risk for suicide in nearly 8 million teens and young adults. Of the 12,669 people 15 to 30 years of age with a first diagnosis of a primary cancer, the relative risk (RR) for suicidal behavior in the year immediately after the diagnosis was 2.5 (95% confidence interval [CI], 1.7 - 3.5).

Overall, the risk for suicidal behavior remained higher in cancer survivors than the cancer-free population (RR, 1.6; 95% CI, 1.4 - 1.9).

"The immediate impact of cancer diagnosis among the young individuals observed in this study appears to be similar to that of the elder adults, with the first year after cancer diagnosis clearly standing out as a highly stressful period," write Donghao Lu, a PhD candidate in the Department of Medical Epidemiology and Biostatistics at the Karolinska Institute in Stockholm, and colleagues.

They speculate that younger cancer patients do not have the coping skills that older adults have developed in response to life-changing events. The findings were published online October 29 in Annals of Oncology.

From Ideation to Action

"Sadly, these results confirm what we suspected from our research looking at suicide ideation," Christopher J. Recklitis, PhD, MPH, director of research and education for the Perini Family Survivors' Center at the Dana-Farber Cancer Institute in Boston, told Medscape Medical News.

In a large American cohort from the Childhood Cancer Survivor Study, "we found increased reports of suicide ideation in childhood cancer survivors, compared with their siblings. Although we hoped that it was only in the realm of ideation and didn't extend to action, these data suggest that, at least in the Swedish cohort, childhood cancer survivors are not just at risk of suicide ideation, but at attempts and completion," said Dr. Recklitis, who was not involved in the study, but whose work was cited by Lu and colleagues.

The investigators linked records from 1987 to 2009 in Sweden's extensive national registration system to each unique anonymous record to the nationwide Cancer, Causes of Death, Migration, and Inpatient Registers.

They followed 7,860,629 people from their 15th birthday until their first suicide attempt, completed suicide, death, emigration, or study end.

During the mean follow-up of 17.4 years, there were 105,868 cases of suicidal behavior, defined as suicide attempt or completion, in people without cancer, yielding an incident rate of 0.78 per 1000 person-years.

In contrast, the incident rate of suicidal behavior in cancer patients was 1.27 per 1000 person-years. Where 14 completed suicides would be expected in the cancer-free population, there were 22 in cancer patients, and where 80 attempts would be expected, there were 136.

After adjustment for age, sex, calendar period, and psychiatric history, risk for suicide was higher after a cancer diagnosis.

In the first year after diagnosis, the risk for completed suicide was 4-fold higher (RR, 4.0; 95% CI, 1.6 - 8.1). After the first year, however, there was no significant increase in risk for completed suicide.

The persistently higher risk for suicide attempt during the entire follow-up period after a cancer diagnosis indicates that many factors — such as the subsequent cancer treatment, physical distress related to cancer and its treatments, disease recurrence, and the potential lack of treatment options in the final disease stages — have an influence on the psychological well-being of young patients, Lu and colleagues write.

As the ranks of survivors of childhood cancer continue to swell, it is incumbent on the healthcare system to ensure that the mental and physical sequelae of cancer therapy are addressed, Dr. Recklitis noted.

"In the modern era of treatment, particularly in childhood and adolescence, we have a lot of survivors, so there is much more attention being paid to survivorship care. But I think creating the structures to make sure that there are enough professionals and that there is enough time, space, and reimbursement for people to get their mental healthcare is definitely a work in progress," he said.

The study was supported by the Swedish Council for Working Life and Social Research, the Swedish Research Council, the Karolinska Institute, and the Swedish Society for Medical Research. The study authors and Dr. Recklitis have disclosed no relevant financial relationships.

Ann Oncol. Published online October 29, 2013. Abstract

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