Studies consistently have shown patients with cancer have a higher risk for suicide than the general public.

A population-based study of more than 4.6 million patients with cancer showed an excess risk for suicide within 1 year after diagnosis of 2.51 per 10,000 person-years. In that study, published in 2019 in Cancer, Saad and colleagues observed the highest increases in suicide rates following diagnosis of pancreatic, lung or colorectal cancer.

A separate meta-analysis of 28 studies by Heinrich and colleagues, published in March in Nature Medicine, showed an 85% higher suicide rate among patients with cancer compared with the general population, with strong correlations of risk with cancer prognosis and stage, time since diagnosis and geographic region.

Other research has shown significantly higher suicide rates among patients with head and neck and brain cancers, as well as patients who reside in rural areas.

Although data published in 2020 in Journal of the National Cancer Institute revealed an overall decline in cancer-associated suicide from 1999 to 2018 — with substantially decreased rates among specific high-risk groups — identification of patients at increased risk remains a critical challenge for oncology professionals.

“Suicide is a huge problem in America, and we will most likely see a significant increase since the COVID-19 pandemic began,” Nosayaba Osazuwa-Peters, PhD, BDS, MPH, CHES, member of Duke Cancer Institute and assistant professor in head and neck surgery and communication sciences and population health sciences at Duke University School of Medicine, told Healio | HemOnc Today. “Patients with cancer are two times more likely to die of suicide compared with people without cancer. This is such an important and critical issue, and we should be talking about suicide risk in patients with cancer more because no patient who survives cancer should die by suicide. We need to be able to support these patients better.”

Healio | HemOnc Today spoke with oncologists and other experts about which patients with cancer may be at highest risk for suicide and targeted interventions that oncology care teams can employ to address the problem.

Rural residents at higher risk

Because many residents of rural and low-income areas lack access to mental health resources, Suk and colleagues hypothesized they may be at higher risk for suicide after cancer diagnosis compared with those who reside in urban and high-income areas.

The researchers investigated differences in suicide mortality risks and patterns based on county-level median income and rural vs. urban status among 5,362,782 people (51.2% men; 72.2% white; 49.7% aged older than 65 years) diagnosed with cancer between 2000 and 2016.

Results of the study, published in JAMA Network Open, showed 6,357 people died by suicide. Among them, people living in the lowest-income counties had a significantly higher risk (standardized mortality ratio [SMR] = 1.94; 95% CI, 1.76-2.13) than those in the highest-income counties (SMR = 1.3; 95% CI, 1.26-1.34). Additionally, those living in rural counties had a significantly higher risk (SMR = 1.81; 95% CI, 1.7-1.92) than those living in urban counties (SMR = 1.35, 95% CI, 1.32-1.39).

Osazuwa-Peters and colleagues reported even larger differences in suicide risk based on area of residence among patients with head and neck cancer.

The cross-sectional study, published last year in JAMA Otolaryngology-Head & Neck Surgery, included data from the SEER database on 134,510 patients (mean age, 57.7 years; 75.2% men) diagnosed with head and neck cancer between 2000 and 2016. Overall, 86.6% of the study population resided in metropolitan areas, 11.7% resided in urban areas and 1.7% resided in rural areas.

Researchers identified 405 suicides. They observed a significantly higher risk for suicide among patients who resided in rural (SMR = 5.47; 95% CI, 3.06-9.02), urban (SMR = 2.84; 95% CI, 2.13-3.71) and metropolitan areas (SMR = 2.78; 95% CI, 2.49-3.09) compared with the general population.

“We hypothesize that the cancer care provided in rural areas is not uniform across the board,” Osazuwa-Peters said. “Many comprehensive cancer centers are in urban and metropolitan areas, and not every [patient with cancer] who resides in a rural area is able to travel repeatedly to the city to receive care. In addition, patients residing in rural areas may not have access to psychosocial care and/or may have greater access to lethal means.”

For these reasons, it is important to integrate mainstream psychosocial services for patients with cancer, Osazuwa-Peters added.

“We should not wait for our patients to exhibit signs of suicide before we act. Instead, psychosocial services should be embedded into mainstream cancer care proactively,” he said. “This takes away the stigma and the lack of patients wanting to have a conversation about it in the first place.”

A separate study by Osazuwa-Peters and colleagues, published in April in Journal of Cancer Survivorship, reinforced the idea that increased health care access could reduce the risk for suicide among some patients with cancer. The study showed an Affordable Care Act-associated decrease in suicide incidence among some nonelderly patients with cancer, particularly young adults aged 18 to 39 years in Medicaid expansion vs. nonexpansion states (64.36 per 100,000; 95% CI, 125.96 to2.76).

Psychiatric risk factors

It is also important for clinicians to note the psychiatric risk factors associated with suicide risk among patients with cancer, including a history of depression or other psychiatric illness, according to Jeffrey Kendall, PsyD, LP, oncology psychologist at MHealth Fairview Oncology Service Line.

“A giant red flag is a previous suicide attempt,” Kendall told Healio | HemOnc Today. “Other big psychiatric red flags are a sense of hopelessness or demoralization — pain from the cancer itself and/or treatment, lack of social support, feeling like a burden to others, regret, loss of meaning and purpose and loss of dignity.”

Chang and colleagues found depression to be the most common psychiatric disorder among 459,542 adults diagnosed in Britain with any of 26 different cancers. Results of their study, published in March in Nature Medicine, also showed the highest burden of psychiatric disorders among patients who received alkylating-agent chemotherapeutics, and the lowest burden among those who receive kinase inhibitors.

“All mental illnesses were associated with an increased risk of subsequent self-harm, where the highest risk was observed within 12 months of the mental illness diagnosis,” the researchers wrote.

Sociodemographic factors also play a role in suicide risk, according to Kendall.

“For example, older, white males are lethal, and if the elderly white male is unmarried and has a poor social network, that makes him even more lethal,” he added. “People who are of lower socioeconomic status, less educated and lack social support are some of the most lethal groups. Education level and support network are key variables.”

Patients with cancer and a poor prognosis should be directed to psychological support programs on the day of diagnosis, according to Ahmad Samir Alfaar, MBBCh, MSc, researcher at Leipzig University in Germany.

“These programs should involve their families and friends, as well,” Alfaar told Healio | HemOnc Today in a 2020 interview. “These plans should be supported by evidence and personalized to address the needs of each patient.”

Data that highlighted an association of brain tumors and mental health prompted Alfaar and colleagues to investigate suicide risk after brain cancer diagnosis compared with the overall U.S. population.

In a research letter published in JAMA Network Open, they reported that among 87,785 patients with brain cancer diagnosed between 2000 to 2016, 29 (0.03%) died by suicide within the first year of diagnosis, whereas 33,993 (38.7%) died of cancer and other causes. The investigators calculated an observed-to-expected event ratio — with the expected number of events equal to the number of people estimated to die of the same cause in a demographically similar general population during the same time frame — for suicide risk of 3.05 (95% CI, 2.04-4.37).

“Further studies should be conducted to discover the relationship of each treatment milestone and the relation to the timepoints of extreme psychiatric situations among patients with cancer,” Alfaar said.

Prevention strategies

Experts with whom Healio | HemOnc Today spoke said communication is key to address suicide risk among patients with cancer.

“One in two patients may have some form of depression and may not be willing to talk about it, so physicians need to ask about it more and, in turn, patients need to be more engaged with their providers to talk about their struggles,” Osazuwa-Peters said. “Oncologists may be the ones to see these issues and flag them before it is too late. Many of these patients may never seek mental health care before they die by suicide.

“Communication is key, it sounds so simple, but it is key,” he added. “Society may make the patient feel like they should be so grateful for being alive, but deep down inside they feel like checking out; they need to be able to talk with someone.”

Kendall agreed and said that every cancer center, big or small, should implement distress screening and follow up on the results.

“This is a short-term solution, and if there are stragglers out there that have still not implemented a distress screening program, they need to get that up and running,” Kendall said. “Centers need to hire adequate psycho-oncology staff or, if they are a small community practice and cannot fund that, there needs to be a robust community referral pattern and a feedback loop — medical staff must talk to each other.”

In the long term, the best way to mitigate suicide risk is through evaluation of patient-reported outcomes in a timely manner, Kendall added.

“The emotional and social impact of cancer can be as devastating as the physical illness itself, and to ignore those symptoms is to provide low-quality cancer care,” Kendall said. “The identification, evaluation and intervention of those symptoms should be the standard of cancer care.”

Osazuwa-Peters said it is also important to understand that depression is not the only risk factor for suicide.

“Pain is an independent risk factor for suicide with or without depression. Financial toxicity, irrespective of depression, can lead to suicide. There are multilevel factors that may exacerbate suicidal tendencies beyond depression,” Osazuwa-Peters said. “We need to talk about these factors, as well, independent of depression when it comes to suicidality.”

Another goal is to intervene at the level of ideation.

“There are tools that have not been used extensively in oncology, and I am advocating for these tools to be tested in the oncology setting, see how they work and then make them part of mainstream care. If we can do this during every clinical encounter, we may be able to prevent suicide,” Osazuwa-Peters said.