Cancer Surgery Linked to Higher Suicide Risk

The incidence of suicide was significantly higher in patients undergoing cancer surgery compared with the general U.S. population, a retrospective population-based cohort study showed.

Among patients undergoing surgery for the 15 deadliest cancers in the U.S. from 2000 to 2016, the suicide rate was 14.5 per 100,000 person-years -- a rate that was significantly higher compared with the general population after adjustments for age, sex, race, and calendar year of death (standardized mortality ratio [SMR] 1.29, 95% CI 1.23-1.36), reported Chi-Fu Jeffrey Yang, MD, of Massachusetts General Hospital in Boston, and colleagues.

About half of suicides occurred within the first 3 years after surgery, while 3% and 21% occurred within the first month and first year, respectively, they noted in JAMA Oncology.

"These findings suggest the need to implement suicide screening among patients undergoing cancer operations, especially patients whose demographic and tumor characteristics are associated with the highest suicide risk," Yang and team wrote.

Specifically, compared with the general population, the incidence of suicide was statistically significantly higher among patients undergoing surgery for the following sites of cancer:

• Larynx: SMR 4.02 (95% CI 2.67-5.81)
• Oral cavity and pharynx: SMR 2.43 (95% CI 1.93-3.03)
• Esophagus: SMR 2.25 (95% CI 1.43-3.38)
• Bladder: SMR 2.09 (95% CI 1.53-2.78)
• Pancreas: SMR 2.08 (95% CI 1.29-3.19)
• Lung: SMR 1.73 (95% CI 1.47-2.02)
• Stomach: SMR 1.70 (95% CI 1.22-2.31)
• Ovary: SMR 1.64 (95% CI 1.13-2.31)
• Brain: SMR 1.61 (95% CI 1.12-2.26)
• Colon and rectum: SMR 1.28 (95% CI 1.16-1.40)

Patients undergoing surgery for cancers with higher 5-year overall survival rates had lower SMRs compared with patients undergoing surgery for cancers with lower 5-year rates (slope -0.022, 95% CI -0.039 to -0.004, P=0.02). Of note, patients who underwent surgery for cancers with 5-year overall survival rates greater than 80% -- such as cancers of the corpus uterus, kidney, breast, and cervix -- showed no statistically significant increased incidence of suicide relative to the general population, the authors said.

The median time from surgery to suicide varied by cancer site and ranged from 11.5 months for patients with brain cancers to 78 months for those with cervical cancers.

Patients who were male, white, and divorced or single were at greatest risk for suicide. According to Yang and colleagues, the combined effects of cancer site and patient characteristics increased suicide risk. For example, they reported that white men undergoing surgery for laryngeal cancer had a suicide rate (per 100,000 person-years) that was 63 times greater than that of Black women undergoing surgery for breast cancer.

While major medical professional societies recommend that patients with cancer be screened for distress, adherence to these recommendations is low, the authors noted. Furthermore, these screening efforts are more likely to be implemented in medical oncology practices and not surgical oncology practices, they added.

"Thus, distress screening implemented in medical oncology practices may never reach patients who undergo cancer operations," they wrote. "Further work is needed to develop and implement distress screening programs in surgical oncology practices and to ensure that such programs adequately address the unique psychosocial needs of patients undergoing cancer operations."

In an editorial accompanying the study, Craig J. Bryan, PsyD, ABPP, of the Ohio State University in Columbus, and colleagues noted that one in six patients have pre-existing psychiatric conditions -- conditions that are not only associated with suicide risk, but other outcomes as well, including perioperative complications, longer hospital stays, higher rates of readmission, and increased risk of postoperative suicidal ideation.

Thus, the results of this study not only emphasize the importance of screening patients with cancer for psychiatric conditions and suicide risk, but also "highlight the importance of ensuring access to evidence-based psychological and behavioral treatments both before and after cancer surgery," they wrote.

For this study, Yang and colleagues used data from the Surveillance, Epidemiology, and End Results Program database to examine the incidence and timing of suicide among patients undergoing surgery for the 15 deadliest cancers in the U.S. from 2000 to 2016.

They included 1,811,397 patients (median age 62, 74.4% women). Of these patients, 1,494 (0.08%) died by suicide after undergoing surgery for cancer.

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