High Suicide, Depression Risks for Patients With Cancer

Nancy A. Melville

April 25, 2022

Living with cancer can be emotionally devastating. Now, two expansive studies underscore the scale of the burden a cancer diagnosis and treatment can have on patients' mental health and risk of suicide.

In one, a meta-analysis of 28 studies that included more than 22 million patients, researchers found that among people with cancer, the suicide rate was nearly twice that of the general population. The highest risk was among patients with poor prognoses.

In the other — an analysis of health records from 460,000 people who had been variously diagnosed with 26 cancer types, more than 1% of patients reported engaging in self-harm following their cancer diagnosis. Rates were higher among those who already had been diagnosed with a psychiatric illness.

"Despite their different approaches and outcomes, the two studies emphasize the huge importance of ongoing work to implement appropriate screening tools and improve access to supportive care" following a cancer diagnosis and during treatment, according to authors of a commentary that accompanied the studies, which were published March 28 in Nature Medicine. "A sensible strategy may be to approach patients early in their cancer journey and to place special focus on those cancers with higher rates of psychiatric burden and/or suicide risk," the editorialists write.

Suicide Risk and Cancer

Corinna Seliger-Behme, MD, senior author of the meta-analysis, had expected to see a difference between those with and those without cancer. Previous research had indicated higher suicide rates among patients with cancer in the US.

But the study results still came as a bit of a shock.

"We hypothesized that suicide rates would be higher among cancer patients but were still surprised how high the numbers really were," Seliger-Behme, of the Department of Neurology, University Hospital Heidelberg, Germany, told Medscape Medical News.

The meta-analysis, which the authors describe as the "largest and most comprehensive" on suicide mortality in patients with cancer, involved a systematic review of 28 high-quality cohort studies that included more than 22.4 million patients with cancer in the US, Europe, Australia, and Asia.

The team assessed the risk of suicide mortality on the basis of factors that included cancer prognosis, stage, geographic region, and time since diagnosis.

The overall suicide rate was 85% higher among those with cancer compared with the general population (standardized mortality ratio [SMR], 1.85).

The highest suicide rates were among patients with a poor prognosis; the rates were more than three times greater than among the general population. Cancers associated with poor prognoses — defined as a 5-year survival rate below 50%— included liver and biliary system cancer (SMR, 3.13), mesothelioma (SMR, 13.07), pancreas cancer (SMR, 6.42), and esophageal cancer (SMR, 6.01). Similarly, the rates of suicide were significantly higher among those who had been diagnosed with cancer in the past year.

Geography played a role as well. Suicide mortality among patients with cancer was significantly higher in the US, compared to Europe, Australia, and Asia. Similar geographic differences in suicide mortality did not exist in the general population.

Ethnicity did not appear to be a notable suicide risk factor. Overall, among Black Americans, the suicide mortality rate was slightly less than that among persons of other ethnic groups.

Notably, despite substantial improvements in survival rates and treatments for many cancers, the authors did not find significant differences in suicide mortality before and after 2000, Seliger-Behme said.

"Access to professional medical care and follow-up should therefore represent an integral component of any cancer therapy," the authors write. "Recognizing and attenuating the adverse psychological impact of a cancer diagnosis may not only reduce suicide rates but also improve overall quality of life."

Prior Mental Health Illness Increases Risk

In the second study, Alvina G. Lai, PhD, from the Institute of Health Informatics, University College London, with co-author Wai Hoong Chang, evaluated the health records of nearly 460,000 people who had been variously diagnosed with 26 types of cancer between 1998 and 2020 in the UK.

Overall, Lai and Change found that depression was the most common psychiatric disorder among patients with cancer, followed by anxiety disorders, schizophrenia, bipolar disorders, and personality disorders. More than 25% of those with cancer had substance abuse disorder.

About 1% of patients reported an episode of self-harm after their cancer diagnosis. Among the five psychiatric disorders analyzed, the highest rate of self-harm was among patients with depression, especially within a year of their cancer diagnosis (adjusted hazard ratio, 44.1).

Rates of suicide attempts were also higher among patients from socioeconomically disadvantaged regions and those diagnosed with brain tumors, prostate cancer, Hodgkin's lymphoma, melanoma, or testicular cancer. Overall, testicular cancer was associated with the highest rates of all mental health disorders.

In addition, the authors found that those who had a preexisting mental health disorder reported higher rates of self-harm.

Treatment with surgery, radiotherapy, and chemotherapy represented the leading risk factor associated with developing a mental health condition. Treatment with more aggressive alkylating chemotherapy agents was also linked to a higher psychiatric burden, while treatment with less aggressive radiotherapy or kinase inhibitors was associated with the lowest risk.

"We have shown that psychiatric disorders have a major impact on life after cancer diagnosis, where patients with psychiatric illnesses had a higher incidence of mortality and suicide risk and experienced excess [years of life lost]," the authors conclude.

A Need for Mental Health Interventions

While clinicians may be aware of the elevated risks of psychosocial symptoms among people with cancer, many may "not have enough time to go deeper into this subject with the patient," editorial co-author Cristiane Decat Bergerot, of the Centro de Câncer de Brasilia, Instituto Unity de Ensino e Pesquisa, Brasilia, Brazil, told Medscape Medical News.

Decat Bergerot recommends that patients and caregivers pay special attention to their emotional state — the characteristics and duration of symptoms and whether symptoms interfere with their daily lives or relationships.

Seliger-Behme added that oncologists should also remain vigilant for red flags, which can include new-onset or worsened depressive symptom.

"Interventions that could help improve suicide rates include increased awareness of suicidality in cancer patients, enhanced screening for suicidal thoughts and intentions among cancer patients, and early interventions with specialized psychologic, psychiatric, and palliative care," she said.

The authors and editorialists have disclosed no relevant financial relationships.

Nat Med. Published March 28, 2022. Seliger-Behme et al, Abstract; Chang and Lai, Abstract; Editorial

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