Author: Roxanne Nelson, RN, BSN
Date: Feb. 20, 2018
ORLANDO, Florida — Head and neck cancer (HNC) accounts for only about 4% of new cancer cases in the United States, but the risk for suicide among survivors is significantly higher than for survivors of all other cancer types, with the exception of pancreatic cancer.
“The risk of suicide is significantly elevated across cancer sites, and the risk is especially high among HNC and pancreatic cancer survivors,” said Nosayaba Osazuwa-Peters, BDS, MPH, CHES, instructor, Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, Missouri.
“Cancer survivors are candidates for suicide-related psychosocial surveillance,” he added.
Cancer is the number 2 cause of death in the United States and accounts for 1 of every 4 deaths. Suicide is the tenth cause of death, independent of cancer. “If you add cancer to it, you get the perfect storm,” he said.
“Survivorship does come at a cost, and this is one of the more unfortunate costs of cancer survivorship,” Osazuwa-Peters told delegates here at the Cancer Survivorship Symposium (CSS) Advancing Care and Research.
Currently, there are more than 16 million survivors in the United States. The good news is that more people are surviving cancer, and there is now more focus on competing causes of death and comorbidities, he explained. There is also more focus on the increased risk for acute and late toxicities, which needs to be addressed as the rate of survival increases.
Osazuwa-Peters pointed out that there are “a lot of unmet psychosocial needs and struggles with functionality in this population. The overall risk of suicide among cancer survivors is 50% higher than in the general population.”
Findings from a recent study presented in 2017 at the European Psychiatric Association Congress found that a diagnosis of cancer significantly increases an individual’s risk of dying by suicide by 55% as compared to those without cancer.
“Throughout the lifetime of a survivor, the risk of suicide consistently remains higher,” Osazuwa-Peters pointed out.
Suicide Risk Significantly Higher in HNC
In this study, Osazuwa-Peters and colleagues sought to estimate the incidence of HNC-associated suicide in comparison with other common cancers and to quantify the suicide rate among HNC survivors compared with survivors of cancers other than HNC.
They used data from the Surveillance, Epidemiology and End Results (SEER) database from 2000-2014 to identify all cancer deaths that were confirmed as suicide. The death rates from suicide were estimated for the 21 most common cancers, including HNC.
SEER data revealed that there were 4513 suicides among 4,235,657 cancer survivors during that time frame. This extrapolates to an incidence rate of 23.6 suicides per 100,000 person-years.
For cancers in all other sites combined, the suicide rate was 45% lower than for HNC for both males (mortality rate ratios [MRRs] = 0.55; 95% confidence interval [CI], 0.48 – 0.64) and females (MRR = 0.55; 95% CI, 0.37 – 0.81).
Pancreatic cancer was the only cancer type in which the suicide rate was higher than for HNC (86.4 suicides per 100,000 person-years for pancreatic cancer vs 63.4 suicides per 100,000 person-years for HNC). When stratified by sex, this finding held true only for males; the suicide MRR was significantly higher for male pancreatic cancer survivors compared to that of HNC survivors (MRR = 1.54; 95% CI, 1.23 – 1.90). For females, the suicide MMR was highest with HNC compared with all other cancer types.
“A lot of conversation revolves around depression and fear, but depression does not equate to suicide, and data show that even patients who screen okay for depression still commit suicide,” said Osazuwa-Peters. “There are other factors, such as pain and fear, that may heighten the risk of suicide.”
It is important “that suicide is tackled as a problem” when guidelines are developed by the National Comprehensive Cancer Network and other major players, he said.
In a discussion of the paper, Christopher J. Recklitis, PhD, MPH, director of research at the Perini Family Survivors’ Center, Dana-Farber Cancer Institute, Boston, Massachusetts, noted that the suicide risk among cancer survivors has been studied for a while, and it has previously been suggested that HNC survivors are particularly at risk.
“This study is important because it focused on head and neck cancers, which isn’t often seen, and we can say that these data are largely confirmatory showing the elevated risk,” he said. “My take on this is that it highlights the need for better integration of mental health care into medical survivorship care.”
Not only does the risk for suicide need to be considered, but in general, the psychosocial needs of this population need to be considered more broadly, because suicide is something of a “misery index,” he commented.
“The number of people who are unfortunately ending their lives through suicide suggests that there is large group of people who are quite miserable and thinking about suicide and suffering in a way that needs attention,” he said.
But the study opens the door to several questions, he noted, namely, what is it about HNC that explains this excess risk?
“HNC survivors face poor prognosis, pain, disfigurement, and functional impairments, but that can be said of other cancer survivors,” he pointed out. He added that this group also has a higher risk for substance abuse and depression, but it is not known whether that risk contributes to risk for suicide.
“We need to understand these risks better so we can identify patients at risk and provide effective interventions, and also support the medical providers caring for this high-risk group,” Recklitis added. “We also need to move beyond registry data and study the risk over the course of survivorship, as it can change over time.”
Dr Osazuwa-Peters and Dr Recklitis have disclosed no relevant financial relationships.
Cancer Survivorship Symposium (CSS) Advancing Care and Research. Abstract 146, presented February 17, 2018.