Kate Johnson

March 31, 2015

MADRID — The risk for suicide and accidental death is higher in the first year after a diagnosis of prostate cancer than other cancers, new research shows.

The risk for suicide is not higher overall, but it is during the first year, "specifically in men who are not treated," said investigator Christian Meyer, MD, from Brigham and Women's Hospital and Harvard Medical School in Boston.

This finding comes from an analysis of diagnosis data from the Surveillance, Epidemiology, and End Results (SEER) database, presented here at the European Association of Urology 30th Annual Congress.

Dr Meyer was one of many at the meeting who presented research on patient dissatisfaction with follow-up and the information provided after a prostate cancer diagnosis.

A patient and support-group leader emphasized the psychological burden of being on active surveillance "when all we want to do is get this cancer out of us."

Dr Meyer's team identified 524,965 men diagnosed with adenocarcinoma of the prostate and 956,576 men diagnosed with other solid cancers in the SEER database.

The risk for suicide was higher in men with prostate cancer than in men with other cancers in the first 3 months after diagnosis (adjusted relative risk [aRR], 3.98) and 4 to 12 months after diagnosis (aRR, 2.74).

 
If a man is waking up in a cold sweat at night, we have not done him any favors.
 

The pattern was the same for accidental death; the risk was higher in men with prostate cancer in the first 3 months after diagnosis (aRR, 4.22) and 4 to 12 months after diagnosis (aRR, 2.91).

In men with nonmetastatic prostate cancer, the risk for suicide was lower in black men than in white men (hazard ratio [HR], 0.32; P < .001), but was higher in uninsured than insured men (HR, 4.37; P = .001), in untreated than treated men, whether or not treatment was recommended (HR, 1.44; P < .001), and in unmarried than married men (HR, 2.05; P < .001).

Similarly, the risk for accidental death was lower in black men than in white men (HR, 0.88; P = .053), but was higher in uninsured than insured men (HR, 2.18; P = .124), in untreated than treated men, whether or not treatment was recommended (HR, 1.44; P < .001), and in unmarried than married men (HR, 1.53; P < .001).

"The message is look at your patients and keep track of, for example, your unmarried white guy without insurance during the first year after a diagnosis," said Dr Meyer. "Follow him up and try to evaluate whether there are any underlying issues that might impact the risk of suicide. A referral is an easy task if somebody does not choose treatment. If you have the feeling there are some underlying issues — may they be mental health or whatever — it's pretty easy to give them a referral for counseling and to try to ensure that they seek help."

Dr Meyer acknowledged that there are unanswered questions raised by the SEER data, some specific to the United States.

Risk in Context

Comorbidities could not be gleaned from the data, so the researchers could not determine if deaths were due to depression. They also weren't able to determine reasons for nontreatment. "We have to be very careful about assuming" that these patients were on active surveillance, said Dr Meyer.

"There are racial disparities in the treatment of prostate cancer in the United States, but interestingly, blacks had a lower suicide risk than whites," he added.

"This work establishes that there is a risk of suicide in men diagnosed with prostate cancer, which is particularly high in the first 12 months following diagnosis and in those in whom a definitive decision to proceed with active treatment is not made," said session moderator Derek Rosario, MD, from the University of Sheffield in the United Kingdom.

Clinicians should be aware of this and of the possible background indicators, he told Medscape Medical News.

In fact, he cited one meta-analysis in which clinically relevant depression was found to be present in 17% of men before a diagnosis of prostate cancer, and the prevalence of clinically relevant pretreatment anxiety was found to be high, at 27% (BMJ Open. 2014;4:e003901).

 
There's a growing number of people who think we shouldn't really be calling these things cancer.
 

"This should be taken into account when discussing treatment options; perhaps active surveillance is not as good a treatment option for some men. This is something that should be tested prospectively," he said.

After a diagnosis, "the data suggest that enhanced support, including specific psychological support, should be offered, particularly to men on active surveillance, and the importance of peer support cannot be understated," he added.

Suicide in cancer patients is "a somewhat neglected problem," said Christopher Recklitis, PhD, from the Perini Family Survivors' Center at Harvard Medical School in Boston, who was not involved in the study.

In a previous study, suicide rates were found to be higher in men with prostate cancer than in men without cancer (J Clin Oncol. 2008;26:4731-4738). However, in that study, other cancers were a greater risk than prostate cancer.

"Nonetheless, it is important to continue to investigate the problem of suicide in men diagnosed with prostate cancer because it is the most common cancer in men," Dr Recklitis explained. "It often has a good prognosis and people sometimes assume that men will make a good adjustment to their diagnosis. In addition, men often live for many years after a diagnosis of prostate cancer, and studies have shown the risk for suicide remains elevated even decades later."

The study by Dr Meyer's team is "intriguing," he said. It suggests that there is "something about the cancer diagnosis in these men or their ability to cope with the diagnosis that puts them at greater risk for suicide. In addition, it suggests that providers may want to have an elevated concern about the psychological welfare of men who have difficulty engaging with treatment."

The elevated suicide risk in men with prostate cancer is "a failure of the clinician who gave the diagnosis," said Matt Cooperberg, MD, from the University of California, San Francisco.

"The first thing we need to say when we tell someone they have prostate cancer is that this is not pancreatic cancer, this is not lung cancer. If a man is waking up in a cold sweat at night, we have not done him any favors," he told Medscape Medical News.

Even in cases of advanced prostate cancer, clinicians have a responsibility to put a patient's risk in context, he said. And in cases where the disease merits active surveillance, clinicians should take time to make sure that the patient is sufficiently reassured.

"There's a growing number of people who think we shouldn't really be calling these things cancer," Dr Cooperberg said, referring to low-risk disease. "Yes, pathologically this looks like a cancer, but it's not a malignancy, it doesn't behave like a malignancy, and it doesn't spread."

Dr Meyer, Dr Rosario, Dr Recklitis, and Dr Cooperberg have disclosed no relevant financial relationships.

European Association of Urology (EAU) 30th Annual Congress: Abstract 366. Presented March 22, 2015.

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