Cancer surgery linked to increased risk of suicide

New research reveals elevated suicide rates among adults undergoing surgery for cancer, with half of the suicides occurring during the first three postoperative years.

The study, led by a team of researchers from Harvard-affiliated Massachusetts General Hospital, was published in JAMA Oncology and highlights the need for regular screening for distress and assessment for suicide among such patients.

“Several studies have now shown that the incidence of psychiatric morbidity among patients undergoing cancer operations is high — an estimated 6 to 38 percent 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, 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 MGH.

“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 U.S. cancer statistics — for patients undergoing surgery for the 15 deadliest cancers.

“The incidence of suicide, compared with the general population, was significantly higher for patients undergoing surgery for 10 of the 15 cancers evaluated.”

Chi-Fu Jeffrey Yang, thoracic surgeon at MGH

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

The incidence of suicide, compared with the general U.S. 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 percent, 21 percent, and 50 percent 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 three years after surgery, which is a time when many patients are often still regularly following up with their health care 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 five-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.”

Additional study co-authors include Alexandra L. Potter, Chinmay Haridas, Krista Neumann, Mathew V. Kiang,
Zhi Ven Fong, Corinne A. Riddell, and Harrison G. Pope Jr.