Patients undergoing major cancer operations at significantly elevated risk of suicide

Massachusetts General Hospital researchers have found in a new study that among adults undergoing surgery for cancer, the rates of suicide were elevated. Further half of the suicides occurred during the first three postoperative years.The study highlights the need for regular screening for distress and assessment for suicide among such patients.

The study has been published in JAMA Oncology. 

“Several studies have now shown that the incidence of psychiatric morbidity among patients undergoing cancer operations is high-an estimated 6 to 38% of patients develop major depressive symptoms after surgical treatment. However, the risk of suicide among patients undergoing cancer operations remains largely unknown,” says senior author Chi-Fu Jeffrey Yang, MD, a thoracic surgeon at MGH and an assistant professor of surgery at Harvard Medical School.

“Additionally, there are currently no organized programs in place to implement regular screening for distress among this patient population.”

“Many patients who undergo cancer operations-particularly those diagnosed with early-stage disease-achieve excellent long-term survival rates. Most patients undergo these operations with the intent that surgery will provide them with the best prognosis possible,” says first author Alexandra Potter, a researcher at Mass General.

“However, cancer surgery can be stressful, and patients can face long and complicated postoperative recoveries. These factors, combined with the high rate of psychiatric morbidity among patients undergoing cancer operations, may contribute to an increased risk of suicide in this patient population.”

To better understand the incidence, timing, and factors associated with suicide among patients undergoing cancer operations, Yang and his colleagues examined data from the Surveillance, Epidemiology, and End Results Program—which provides information on US cancer statistics-for patients undergoing surgery for the 15 deadliest cancers.

The investigators found that from 2000–2016, suicides occurred in 1,494 of 1,811,397 patients (0.08%) who underwent cancer operations.

The incidence of suicide, compared with the general US population, was significantly higher among patients undergoing surgery for cancers of the larynx, oral cavity and pharynx, esophagus, bladder, pancreas, lung, stomach, ovary, brain, and colon and rectum.

Approximately 3%, 21%, and 50% of suicides were committed within the first month, first year, and first three years after surgery, respectively. Patients who were male, white, and divorced or single faced the greatest risk of suicide.

“The incidence of suicide, compared with the general population, was significantly higher for patients undergoing surgery for 10 of the 15 cancers evaluated,” says Yang. “Also, approximately half of suicides occurred during the first 3 years after surgery, which is a time when many patients are often still regularly following up with their healthcare team."

"Thus, this period is an opportunity to potentially develop and implement programs to regularly screen patients for distress and ensure that patients have access to the appropriate support and treatment if needed.”

Yang notes that screening for psychosocial distress is recommended by several major medical professional societies for all cancer patients, regardless of their treatment, but efforts to implement screening in clinical practice have mostly focused on integrating screening in medical oncology practices and not surgical oncology practices.

“Many early-stage cancer patients who undergo cancer surgery receive their primary cancer care through their surgeon and many do not ever see a medical oncologist,” says Yang.

“Because distress screening implemented in medical oncology practices may never reach patients who undergo cancer operations, further work is needed to develop and implement distress screening programs in surgical oncology practices.”

The researchers are hopeful that their findings will spur efforts to develop effective strategies for suicide screening, assessment, and treatment for these patients.

An accompanying editorial stresses the importance of considering how many suicide cases in the study were terminal, meaning that the patients’ deaths were expected to occur within six months. (Indeed, patients undergoing surgery for cancers with lower 5-year survival rates had higher suicide rates.)

"Research aimed at understanding the similarities and differences between suicidal states, as classically defined, and end-of-life considerations among patients with terminal illness warrants further attention,” the editorial’s authors wrote. “Such research could advance the understanding of suicide and how to best prevent it across patient populations and to reveal clues for delivering compassionate and effective care for patients with cancer.”

Reference:

Potter AL, Haridas C, Neumann K, et al. Incidence, Timing, and Factors Associated With Suicide Among Patients Undergoing Surgery for Cancer in the US. JAMA Oncol. Published online January 12, 2023. doi:10.1001/jamaoncol.2022.6549