Despite improved survival rates among cancer patients, the risk of death by suicide remains high, especially among those treated for head and neck cancers (HNC). Researchers at the Saint Louis University School of Medicine report that HNC survivors are twice as likely to commit suicide as survivors of other cancers and four times more likely that the general population.
“This problem of suicide is bigger than many realize. In the general US population, suicide is the tenth leading cause of death,” said Nosayaba Osazuwa-Peters, BDS, PhD, MPH, assistant professor of otolaryngology and faculty member at the Saint Louis University Cancer Center. “But to think that it might be an even bigger problem among cancer survivors is staggering.”
More than 15.5 million individuals are living with a cancer diagnosis, and the number of cancer survivors is projected to be more than 20 million by 2026, the researchers report. Three percent of those diagnosed patients have head and neck cancer. Yet surviving cancer comes with a cost, Osazuwa-Peters said.
While the need to survive overtakes concerns about functionality and aesthetics, about half of HNC survivors become functionally disabled after completing treatment and are unable to return to work. Persistent and lasting disfigurements or loss of skills may increase depression, psychological distress, fear of recurrence, and suicidal ideation.
“Now more than ever before, people are outliving their cancer diagnosis. This makes lifelong surveillance critical. Being considered a cancer survivor does not tell you how well the individual is doing,” Osazuwa-Peters said. “Some cancer survivors unfortunately decide that it is better that they are dead rather than being alive.”
Survivors were identified from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) 18-registry database using patients diagnosed between 2000 and 2014. It is a publicly available, nationally representative population-based cancer database that includes more than 8 million cases with data spanning four decades covering 28% of the US population.
The study looked at patients over the age of 20 who had a first primary malignancy of the head or neck, including squamous cell carcinomas of the oral cavity, pharynx, larynx, nasal cavity, and sinuses. The suicide rate among these patients was compared to those diagnosed with other cancers.
The researchers examined data for 4,219,097 cancer survivors, including 151,167 diagnosed with HNC. Between 2000 and 2014, the suicide rate for those with HNC was 63.4 per 100,000. For the period, the rate among other cancer survivors was 23.6 per 100,000. Among the general population, it was 17.4 per 100,000.
The study found that HNC survivors are two times more likely to die by suicide than survivors of other cancers. Those with cancers in the oral cavity and pharynx previously have been found to comprise 20% of the HNC suicide burden among survivors.
HNC survivors have unique treatment needs and distresses, including persistent and late effects of treatment, such as disfigurement and body image issues, swallowing difficulty, ototoxicity, and depression. Pain issues and substance abuse also are more prevalent in this population.
Factors associated with a significantly increased risk of suicide include being a male, white, previously married, or never married; and having regional, distant, and unstaged or unknown stage disease.
Male HNC survivors had an increased risk of suicide compared to survivors of colorectal, Hodgkin and non-Hodgkin lymphoma, kidney, leukemia, liver, melanoma, prostate, testis, thyroid, and bladder cancer. Only pancreatic cancer survivors had a significantly higher risk of suicide than that of those who survived head and neck cancer.
Female HNC survivors had an increased risk of suicide compared to survivors of melanoma, Hodgkin and non-Hodgkin lymphoma, leukemia, uterine, breast, thyroid, colorectal, kidney, and brain cancer.
The study also found 27% increase in death by suicide in the final five years of the study, compared to the period between 2000 and 2004, which corroborates with data from the Centers for Disease Control and Prevention that highlighted a 25% increase in the suicide rate in the general United States population since 1999.
“The rates we found in this study greatly mirror the national trends in terms of increasing incidence of suicide,” Osazuwa-Peters said.
SEER data did not provide information about depression status, a key risk factor for suicide. There also was a lack of information in the data about comorbid psychiatric conditions, family history of suicide, or substance abuse. Individual survivors’ functional status, pain, disfigurement, and other quality of life variables weren’t available in the SEER records either.
Osazuwa-Peters said that while recent cancer initiatives have focused on survivorship and curing cancer, more needs to be done to address distress experienced by cancer patients. The study recommends physicians follow up with patients by assessing mental health concerns and do more to provide further communication and tailored interventions when needed.
The study, “Suicide Risk Among Cancer Survivors: Head and Neck Versus Other Cancers,” was published by Cancer.