COMMENTARY

When Your Cancer Patient Attempts Suicide

David J. Kerr, CBE, MD, DSc

Disclosures

March 11, 2021

This transcript has been edited for clarity.

Hello. I'm David Kerr, professor of cancer medicine at University of Oxford.

I often like to relate these small discussions that we have to patients I have seen in the clinic.

Most of our work is still being done remotely, but we do a face-to-face clinic once a fortnight for patients who are new or particularly keen to see us, or for those with whom we're running into problems. Friday was a problem day.

We saw a 70-year-old gentleman with advanced metastatic colorectal cancer who had just started, with moderate success, second-line chemotherapy to manage his disease. We'd explained that the chemotherapy would be palliative in his case. It would be about buying time and prolonging life but could not be curative, given the pattern of dissemination and spread of disease.

What was unusual about him — a highly intelligent individual, someone whom we had been looking after for 6 months with first- and then second-line chemotherapy — was that he had become clinically depressed. This is not unusual in and of itself, but he had attempted suicide. In the almost 40 years that I've been a cancer doctor, this has been a very unusual occurrence.

Luckily, the patient's wife dealt with it, as did we, with superb support from our consultant psychiatrist colleague. We got him settled, stabilized, more on an even keel, and able to make decisions about the future of his treatment.

It did make me think about the degree of suicidal ideation that may occur.

There was an important population-based study that was conducted in the United Kingdom a couple of years ago. This was an interrogation of a very large public database that was led by researchers from University College London in collaboration with Public Health England, the custodians of our National Cancer Registry and other databases.

They looked back over a 20-year period to look at the suicide rate in cancer patients. Age, gender, and social class were matched and controlled with other observations. Over that 20-year period, they found almost 2500 recorded suicides in the United Kingdom. They discovered that cancer patients had a 20% higher rate of suicide than the general population.

Interestingly, that suicide risk was most predominant during the 6 months after the diagnosis. It also was more predominant in a number of rather aggressive tumor types, including mesothelioma, esophageal cancer, pancreatic cancer, lung cancer, and stomach cancer. There was an interesting clustering around those diseases in which I'm sure the patients had been told that their life expectancy was significantly abbreviated.

The way that we deal with this is for all patients who come to our clinic to fill in a depression score. The depression score, depending on what it is, has a variety of different alarms that go off. There is an amber alert or a red alert. With the amber alert, we have an immediate follow-up with our community psychiatric nurses. If it's a red alert, we have follow-up with our consultant psychiatrist colleague.

We've got a large prospective study going on at Oxford, and it does look as if this system of premonitory monitoring seems to be working. It has broken down in times of COVID-19, though. For example, this particular patient had slipped through the net because he wasn't part of our routine observation using this depression score.

When I went back to look at the data, I thought the suicide risk may have been higher. We know that the diagnosis of cancer is stigmatizing, terrifying, and frightening. No matter how we communicate, no matter how much support we offer, and no matter how clear we are in terms of both what we can and cannot do, I must admit that I thought the suicide risk would have been a little higher given the despair that some patients can plunge into during those first 6 months.

As the frontline consultants dealing with these patients, the burden of communication is on us. I think the idea of having some form of monitoring the psychological state with a well-validated depression score may be something that is worth considering.

I'd be very interested in any thoughts, questions, or comments that you have.

For the time being, Medscapers, as always, thanks for listening. For the time being, over and out.

David J. Kerr, CBE, MD, DSc, is a professor of cancer medicine at the University of Oxford. He is recognized internationally for his work in the research and treatment of colorectal cancer and has founded three university spin-out companies: COBRA Therapeutics, Celleron Therapeutics, and Oxford Cancer Biomarkers. In 2002, he was appointed Commander of the British Empire by Queen Elizabeth II.

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