Suicide risk in patients with head and neck cancer: An area of urgent need
Individuals with cancer are twice as likely to die by suicide than the general population.
Researchers have demonstrated higher suicide rates among individuals with multiple cancer types — including lung, pancreas, stomach, bladder and oral cancers — and have examined demographic and cancer-specific factors that may help to identify vulnerable patients.
Kam and colleagues make a significant contribution by focusing on a high-risk and understudied group: patients with head and neck cancer.
According to data from the SEER database from 1973 to 2011, patients with head and neck cancer are three times more likely to die of suicide than age-, race- and sex-matched controls.
As anticipated, older males — particularly those who are white and unmarried — have higher risk. Suicide rates also are higher in patients with advanced-stage cancer and are highest in the first 5 years after diagnosis, consistent with prior studies demonstrating a vulnerable period immediately following cancer diagnosis.
Patients who received radiation treatment alone had higher suicide rates than those who also received surgery, potentially due to disease stage or comorbidity.
Suicide rates were highest in patients with hypopharyngeal cancer and laryngeal cancer. The researchers suggest that these cancer sites may be associated with loss of ability to eat or speak, critical functions that are closely linked with quality of life, depression and demoralization.
This study adds to mounting evidence of increased suicide rates in patients with head and neck cancer and highlights high-risk subgroups. We are beginning to develop a profile of a high-risk patient — for example, an older white, widowed male recently diagnosed with metastatic laryngeal cancer who will receive radiation. We know very little about this patient’s mental health history and how that impacts risk.
As the researchers acknowledge, SEER does not include information about psychiatric history and substance use. These are critical factors to assess suicide risk in the general population. Importantly, depression, as well as alcohol and tobacco use, are common in patients with head and neck cancer, and these are modifiable factors that can be targeted in an intervention. Further, depression is disabling, and it is associated with poor quality of life and decreased adherence with cancer treatment.
Psychosocial distress also is underrecognized. The American College of Surgeons and leading interdisciplinary organizations call for the integration of distress screening into cancer care. Screening is effective when implemented within a system that facilitates treatment. New approaches to treatment are needed.
Prevention is one strategy. Acknowledging high rates of depression after intensive chemoradiation for oral cancers, Lydiatt and colleagues conducted a randomized, controlled trial that showed patients with head and neck cancer who were proactively treated with escitalopram prior to cancer treatment had lower rates of depression and improved quality of life at 3 months.
Integration of cancer and mental health care is crucial. Collaborative-care approaches utilizing an interdisciplinary team that includes the oncologist or head and neck surgeon, a social worker or nurse, and a consulting psychiatrist show promise, including improved depressive symptoms and quality of life. Given limited access to psychiatry, these interventions also may be easier to disseminate.
Despite the prevalence of alcohol use and depression in patients with head and neck cancer, patients with premorbid mental illness and substance use are frequently excluded from collaborative care trials. Further research on effective interventions that target depression and suicide risk in patients with cancer is urgently needed.
Barber B, et al. J Otolaryngol Head and Neck Surg. 2015;doi:10.1186/s40463-015-0092-4.
Klaassen Z, et al. Cancer. 2015;doi:10.1002/cncr.29274.
Lydiatt WM, et al. JAMA Otolaryngol Head Neck Surg. 2013;doi:10.1001/jamaoto.2013.3371.
Misono S, et al. J Clin Oncol. 2008;doi:10.1200/JCO.2007.13.8941.
Nasseri K, et al. Arch Suicide Res. 2012;doi:10.1080/13811118.2013.722056.
Pirl WF, et al. Cancer. 2014;doi:10.1002/cncr.28750.
Sharpe M, et al. Lancet. 2014;doi:10.1016/S0140-6736(14)61231-9.
Urban D, et al. Chest. 2013;doi:10.1378/chest.12-2986.
Yu GP, et al. JAMA Otolarnygol Head Neck Surg. 2012;doi:10.1001/archoto.2011.236.
For more information:
Kelly E. Irwin, MD, is instructor in psychiatry at Harvard Medical School and faculty psychiatrist at Massachusetts General Hospital Cancer Center. She can be reached at Psychiatric Oncology, 55 Fruit St., Boston, MA 02114-2696.
Disclosure: Irwin reports no relevant financial disclosures.