Incidence, Timing, and Factors Associated With Suicide Among Patients Undergoing Surgery for Cancer in the US

Abstract

ImportanceThe risk and timing of suicide among patients who undergo surgery for cancer remain largely unknown, and, to our knowledge, there are currently no organized programs in place to implement regular suicide screening among this patient population.ObjectiveTo evaluate the incidence, timing, and factors associated with suicide among patients undergoing cancer operations.Design, Setting, and ParticipantsThis retrospective population-based cohort study used data from the Surveillance, Epidemiology, and End Results Program database to examine the incidence of suicide, compared with the general US population, and timing of suicide among patients undergoing surgery for the 15 deadliest cancers in the US from 2000 to 2016. A Fine-Gray competing risks regression model was used to identify factors associated with an increased risk of suicide among patients in the cohort. Data were analyzed from September 2021 to January 2022.ExposuresSurgery for cancer.Main Outcomes and MeasuresIncidence, compared with the general US population, timing, and factors associated with suicide after surgery for cancer.ResultsFrom 2000 to 2016, 1 811 397 patients (74.4% female; median [IQR] age, 62.0 [52.0-72.0] years) met study inclusion criteria. Of these patients, 1494 (0.08%) committed suicide after undergoing surgery for cancer. The incidence of suicide, compared with the general US population, was statistically significantly higher among patients undergoing surgery for cancers of the larynx (standardized mortality ratio [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), and colon and rectum (SMR, 1.28; 95% CI, 1.16-1.40). Approximately 3%, 21%, and 50% of suicides were committed within the first month, first year, and first 3 years after surgery, respectively. Patients who were male, White, and divorced or single were at greatest risk of suicide.Conclusions and RelevanceIn this cohort study, the incidence of suicide among patients undergoing cancer operations was statistically significantly elevated compared with the general population, highlighting the need for programs to actively implement regular suicide screening among such patients, especially those whose demographic and tumor characteristics are associated with the highest suicide risk.

Evidence-Based Strategies to Reduce Suicide Mortality Among Patients With Cancer

“…Potter et al demonstrate that patients who pursued adjuvant cancer therapies had reduced risk of suicide compared with patients who did not. 3 One of the primary motivators for patients to choose these treatments is to prolong life, often at great personal cost. 15 Without a direct conversation about suicide, it is difficult to know whether patients opting against adjuvant treatments are pursuing a better quality of life or attempting to hasten death.…”

“…The importance of early intervention is highlighted by the finding of Potter et al that 21% of patients with cancer who died by suicide did so within the first year of surgery, though this number disguises the considerable range observed across cancer types. 3 Among patients with larynx and brain cancer, for instance, approximately half of the suicides occurred within the first year of surgery. This variability is noteworthy considering that evidence suggesting rates of psychiatric illness are reasonably consistent across cancer types.…”

“…Numerous studies have demonstrated that suicide mortality is elevated among people with cancer, especially cancers with lower 5-year survival . In this issue of JAMA Oncology , Potter et al report that patients who underwent surgery for cancers with lower 5-year survival also died of suicide much sooner than patients with less deadly cancers, implicating the importance of screening patients with cancer for psychiatric conditions and suicide risk. In addition, the data highlight the importance of ensuring access to evidence-based psychological and behavioral treatments both before and after cancer surgery.…”

“…The most compelling implication of the study by Potter et al stems from the finding that patients with deadlier cancers died by suicide much sooner after surgery than patients with more survivable cancers . The observed differences are stark: approximately 5% of the suicides among patients with cervical cancer (overall 5-year survival rate >80%) occurred within the first year vs approximately 50% of the suicides among patients with brain and larynx cancers (overall 5-year survival rate <40%).…”

“…This distinction in psychological states holds profound implications for treatment. Potter et al demonstrate that patients who pursued adjuvant cancer therapies had reduced risk of suicide compared with patients who did not . One of the primary motivators for patients to choose these treatments is to prolong life, often at great personal cost .…”