Suicide After Cancer: Understanding the Challenges Across the Treatment Trajectory

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Andrew Roth, MD

Keith Wilson, PhD

Christopher Recklitis, PhD

Donald Rosenstein, MD

Asking about suicidal thoughts does not put new ideas into someone’s mind, having never been there before. Many cancer patients think about whether it would be better not to be alive at some time or another after diagnosis.

—Andrew Roth, MD

Suicidal thoughts and impulses are among the most challenging symptoms in patients with cancer, and they may occur both during and after treatment. It has long been known that a cancer diagnosis carries an increased risk for suicide, but the problem is not widely addressed. Suicide is one of the few remaining taboo topics of conversation among the general public, and even health professionals are unprepared to understand and respond to their patients’ suicidal thoughts. The topic of suicide after cancer was featured at the 2015 World Congress of Psycho-Oncology, held in late July in Washington, DC.

Caring for suicidal patients is demanding and requires risk assessment, possibly urgent mental health care, knowledge of ways to manage symptoms, clarity about personal and professional ethics, willingness to grant patient autonomy, and recognition of legal liability. Moreover, most suicide research has focused on people with psychiatric rather than physical conditions, making it difficult to know how well it fits with patients with cancer.

Patients With Cancer May Think About It

Andrew Roth, MD, a psychiatrist at Memorial Sloan Kettering Cancer Center, New York, said that he has seen many patients with cancer who, in a variety of ways, express the thought: “If I’m going to die anyway, what difference does it make if I kill myself?” It is best to help patients derive as much meaning and pleasure from life despite the cancer, which may alleviate ideas and plans for suicide, he explained.

The risk for suicide is definitely elevated in patients with cancer, said Dr. Roth. The more comorbidities a patient has, the higher the risk, often double that of the general population.

“We need to integrate principles and practices from the psychiatric setting, especially suicide screening—and especially early after initial cancer diagnosis, when the rate is higher. We want to know if a patient has a history of suicide attempts, poorly controlled pain, a poor prognosis, and physical impairment and/or loss of mobility. Is the patient elderly? Has there been a history of depression?”

Suicide ideation is not necessarily a precursor to the act itself, but it should be talked about. Dr. Roth also said it is important to ask patients with cancer whether they have been or are now thinking about killing themselves and, if so, whether they have a plan in mind. “Asking about suicidal thoughts does not put new ideas into someone’s mind, having never been there before. Many cancer patients think about whether it would be better not to be alive at some time or another after diagnosis.”

Ways to Look at Suicidal Thoughts

Keith Wilson, PhD, Associate Scientist, Ottawa Hospital Research Institute and Staff Psychologist, The Ottawa Hospital Rehabilitation Centre, Canada, reported that palliative care studies have looked at suicidal concerns in three ways: a desire for death, suicidal ideation, and interest in receiving physician-assisted suicide.

All three were addressed in the Canadian National Palliative Care Survey of 381 patients with advanced cancer. Participants were asked their thoughts about suicide, and they were interviewed to determine the presence of common mental disorders. Thirty percent acknowledged a transient desire for death, but only 12% had a genuine desire to die. Some degree of suicidal ideation was reported by 16%, but only 4% thought of it often or knew how they would do it. Close to 6% would have requested assisted suicide at the time of the interview.

“There was overlap across the categories but also differences,” said Dr. Wilson. The prevalence of depression and/or anxiety among participants with a desire for death, serious suicidal ideation, and an interest in receiving assistance with suicide was 52.2%, 53.3%, and 40.1%, respectively.

The study concluded that occasional wishes for death are common among patients with advanced cancer, but more serious concerns are often associated with depression and/or anxiety. Therefore, said Dr. Wilson, “Expression of a desire for death or suicide by a terminally ill patient should raise a suspicion about mental health problems but is not in itself clearly indicative of them.”

Identifying Survivors at Risk

Suicide remains a risk for survivors, sometimes for years afterward, even if cancer has been cured or is in remission. How can this be? Shouldn’t making it through a fatal disease confer a love of life, a sense of profound gratitude?

Apparently not, said Christopher Recklitis, PhD, Associate Professor of Pediatrics, Dana-Farber Cancer Institute and Harvard Medical School. He looked at data from cohort studies of long-term cancer survivors, and compared with the general population, he found a significant increase in suicide ideation and completed suicide. Although the risk decreases as time passes, it depends largely on the site of the cancer, gender, age, and permanent or long-term handicaps and health problems.

Newer studies have examined the relationship of survivor health outcomes with suicidality and revealed that risk is associated with physical function and the late effects of treatment, the latter of which are particularly prevalent in survivors of childhood cancer. Suicidal ideation is driven by physical as well as emotional health, but it is interesting to note that 30% to 45% of survivors with suicidal ideation report no significant symptoms of depression, so screening for emotional distress alone will not always identify suicide risk.

Even if you do not have cancer any longer, if you feel bad much of the time or have major handicapping after-effects, life may not be enjoyable enough to keep going. In fact, said Dr. Recklitis, “Suicide ideation increases with a diminution of self-assessment of overall health, as well as an objective assessment of such. The risk factor is 30% to 50%, and more than half of those people do not have classic symptoms of clinical depression.” Therefore, he said, it is imperative to develop ways to identify survivors at high risk.

Donald Rosenstein, MD, Professor of Psychiatry and Director, Comprehensive Cancer Support Program, University of North Carolina, Chapel Hill, said that even though many patients with cancer and survivors are not clinically depressed as they think about suicide, the Patient Health Questionnaire (PHQ-9) can be a useful assessment tool.

It is a nine-item scale that measures the presence and severity of symptoms of depression. The tool is short and can be administered in person, over the phone, or self-administered. Available in 30 languages, it is well validated and documented. The first eight questions are the ones usually asked of people thought to be depressed, and the last question is about suicide ideation. According to Dr. Rosenstein, however, that question “has been shown to result in fairly high false-positive rates, and so, is not a good choice for broad screening efforts within oncology.” ■

Disclosure: Drs. Roth, Wilson, Recklitis, and Rosenstein reported no potential conflicts of interest.