The threat posed by head and neck cancer extends well beyond the physical disease, according to research presented at the 2020 Multidisciplinary Head and Neck Cancers Symposium.1,2 The pair of studies underscored the high costs of survivorship, including elevated rates of chronic pain, substance abuse, and mental health comorbidities, which render survivors of head and neck cancer nearly twice as likely to die by suicide as those with other cancers.
Shannon M. Nugent, PhD
Shannon M. Nugent, PhD, Assistant Professor of Psychiatry at Oregon Health & Science University and Core Investigator at the VA Portland Health Care System, Center to Improve Veteran Involvement, emphasized that veterans are particularly vulnerable, given significantly higher rates of head and neck cancer compared with the general population. Research by Dr. Nugent and colleagues has helped to identify factors that may place survivors at greater risk of suicide.
“Suicidal self-directed violence events were associated with postcancer chronic pain, precancer mental health or substance use disorder diagnoses, and postcancer mental health treatment utilization,” said Dr. Nugent. “There is an opportunity for those who are already engaged in mental health care and who have chronic pain or a preexisting mental health condition to have more robust screenings for suicide as well as suicide prevention interventions.”
For this study, Dr. Nugent and colleagues identified a national cohort of veterans with a head or neck cancer diagnosis (stages I–IVB) who received any cancer treatment in the VA. The researchers excluded patients who had recurrent head and neck or second primary cancer within the observation period (defined as 1 year prior to 2 years after cancer diagnosis). The researchers then analyzed cancer diagnoses and treatment, mental health/substance use disorder diagnoses and treatment, and pain intensity scores from the VA Corporate Data Warehouse.
The cohort included 10,622 veterans (95% male; mean age, 65) treated between 2012 and 2018. The most common cancer stage was IVA, and most patients had received radiation treatment.
Findings showed that 36% of patients (n = 3,771) met the criteria for postcancer chronic pain. Patients who experienced chronic pain were twice as likely to have a self-directed violence event during their survivorship, said Dr. Nugent. In addition, 22% (n = 2,337) of the cohort had documented precancer mental health or substance use disorders, and these patients were almost three times as likely to have a suicidal self-directed violence event after their cancer diagnosis.
Nearly half of the sample (47%) had at least one treatment encounter during the 2 years after treatment, and the majority of patients (64%) had between one and four encounters. Although the odds ratio associated with each treatment encounter was small, said Dr. Nugent, researchers did observe a cumulative effect.
“We’re conceptualizing this less as a risk factor and more as a measure of mental illness severity and engagement in health care,” Dr. Nugent explained. “Having a greater number of treatment encounters suggests that individuals may already be at higher risk for self-directed violence events.”
Results showed that 108 (1%) veterans had at least a single documented suicide-related event, with 30 patients ultimately dying by suicide. The researchers are planning qualitative interviews to provide more context for their results and a national survey to better understand the risk factors for suicide among head and neck cancer survivors.
Distress Screening and Follow-up
As Dr. Nugent and colleagues strive to curtail suicide among veteran cancer survivors, researchers at the Multidisciplinary Head and Neck Cancer Program at the University of California, Los Angeles (UCLA), are working on enhanced screening methods to detect cancer-related distress. “Compared to other cancer populations, patients with head and neck cancer report significantly higher distress, depression, and anxiety, which can impact quality of life, treatment compliance, and clinical outcomes,” said Stephanie Lazaro, Head and Neck Cancer Program Coordinator at David Geffen School of Medicine, UCLA. “Implementation of systematic distress screening is crucial to the delivery of high-quality cancer care.”
Ms. Lazaro and colleagues screened 245 patients with head and neck cancer for distress between 2017 and 2019 using the UCLA Distress Screener, a one-page intake form completed by patients with head and neck cancer and includes the standard National Comprehensive Cancer Network® (NCCN) Distress Thermometer, an adapted version of the NCCN “Problem List” relevant to head and neck cancer patients’ biopsychosocial concerns, and screening questions for depression and anxiety. Although 142 of the 245 patients screened positive for distress using the NCCN Distress Thermometer, said Ms. Lazaro, an additional 40 patients were identified using direct clinician referrals, for a total of 74% of patients. Of these patients, 76% (138) received same-day evaluation and intervention from the Mind Body team within the Head and Neck Cancer Program.
“Substantial overlap was found between screening methods while still revealing the effectiveness of each method respectively,” said Ms. Lazaro. “Our team aims to address barriers to psychosocial intervention for all high-distress patients and implement distress screening across the continuum at key intervals of cancer care. Our eventual goal is to examine the impact of distress screening and follow-up on long-term patient outcomes.”
DISCLOSURE: Dr. Nugent and Ms. Lazaro reported no conflicts of interest. This study was supported by grants from the American Cancer Society and resources from the VA Portland Health Care System and a VA Locally Initiated Pilot award.
1. Nugent SM, et al: Risk of suicidal self-directed violence among survivors of head and neck cancer: A retrospective cohort analysis. 2020 Multidisciplinary Head and Neck Cancers Symposium. Abstract 8. Presented February 27, 2020.
2. Lazaro S, et al: Distress screening and follow-up among patients within a multidisciplinary head and neck cancer program. 2020 Multidisciplinary Head and Neck Cancers Symposium. Abstract 9. Presented February 27, 2020.