Suicide in multiple myeloma and acute myeloid leukaemia
Authors: M. Björkholm, M. Hultcrantz, S. Kristinsson, L. Brandt, A. Ekbom, Å Derolf
Journal: Annals of Oncology (2007)

It is well established that persons with cancer commit suicide more frequently than those without [1.Hem E. Loge J.H. Haldorsen T. Ekeberg O. Suicide risk in cancer patients from 1960 to 1999.J Clin Oncol. 2004; 22: 4209-4216Crossref PubMed Scopus (170) Google Scholar]. Males generally commit suicide more frequently than females. Head and neck and lung cancer have been associated with a higher risk of suicide. Based on personal clinical experience and the chronic and often devastating character of the disease we postulated that among patients with hematological malignancies, patients diagnosed with multiple myeloma (MM) carried an increased relative risk. Using the Swedish Cancer Registry we identified a total of 24 489 patients with MM and acute myeloid leukemia (AML) diagnosed in Sweden between 1 January 1973 and 31 December 2003 (16 666 with MM and 7 823 with AML). The male-female ratio was 1.17 and 1.02 and the median age 72 and 69 years for MM and AML patients, respectively. Among these patients, 43 suicides were reported to the Swedish Cause of Death Registry. The incidences per 10 000 person years were 6.1 and 8.9 for MM and AML patients, respectively, yielding a standardized mortality ratio (SMR) of 2.35 in MM and 4.58 in AML using the general population as reference. There were more suicides among men (n = 32) than among women (n = 11), but since this is observed also in the general population, the SMR:s for men and women were almost identical (2.69 and 2.62, respectively). The suicide incidence was higher during the first two calendar periods (1973-89; n = 31), with a minor but constant decline in incidence over the study period (Table 1). The suicide SMR was highest during the first two years following diagnosis, but the SMR remained increased even five years after diagnosis. The incidence rate differed little between the age groups. Except for the higher suicide SMR in AML patients, the features described above did not differ between MM and AML (Table 1). Thus, our postulated hypothesis of a higher suicidal rate in MM as compared to the chosen control group of AML patients was not verified. It was consequently of great interest to read in the Journal the recently published article by Kendal [2.Kendal W.S. Suicide and cancer: a gender-comparative study. Ann Oncol. 2007; 18: 381-387Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar]. This author analyzed >1.3 million cancer cases in Ontario, Canada diagnosed 1973-2001 from a gender-comparative perspective. In that study a 4.8 times excess in the overall number of male suicides over females was reported. Among females a hematological malignancy (Hodgkin, non-Hodgkin lymphoma, leukemia or MM) was not associated with a relative increased or decreased suicidal rate. However, males with MM showed an increased rate while a decreased relative suicidal rate was observed in male patients with leukemia. AML was not specifically investigated among the leukemias.Table 1Suicides among patients with AML and MM in relation to sex, age, year and time since diagnosis and calendar periodAML Person time (years)Number of suicidesIncidence/10 000 person yearsRelative risk (95% CI)Multiple Myeloma Person time (years)Number of suicidesIncidence/10 000person yearsRelative risk (95% CI)Sex male5777813.83.02 (0.80–11.37)27 325248.82.74 (1.23–6.09) female653734.6Reference = 1.0024 93383.2Reference = 1.00Year of diagnosis 73–791573319.111.89 (1.24–114.27)10 65087.51.56 (0.63–3.88) 80–894506715.59.69 (1.19–78.72)18 781136.91.44 (0.64–3.21) 90–03623411.6Reference = 1.0022 827114.8Reference = 1.00Years since diagnosis <13833513.01.82 (0.49–6.77)12 913129.32.58 (1.05–6.31) 1–2290526.90.96 (0.18–5.24)17 132127.01.94 (0.8–4.76) 3+557647.2Reference = 1.0022 21383.6Reference = 1.00Age <50492636.10.97 (0.16–5.82)25 1528.01.24 (0.26–5.85) 50–64319426.3Reference = 1.0012 48586.4Reference = 1.00 65+4194614.32.28 (0.46–11.32)37 258225.90.92 (0.41–2.07) Open table in a new tab The outcome of patients with MM has improved significantly since 1973, most prominent in patients below the age of 60 years [3.Kristinsson S. Landgren O. Dickman P.W. Rangert-Derolf Å BjÖRkholm M Patterns of survival in multiple myeloma: A population-based study of patients diagnosed in Sweden from 1973 to 2003.J Clin Oncol. 2007; (; 25: 1993–1999. Epub 2007 Apr 9)Crossref PubMed Scopus (256) Google Scholar]. High-dose melphalan with subsequent autologous stem cell support, thalidomide and a continuous improvement in supportive care probably contribute to this finding [3.Kristinsson S. Landgren O. Dickman P.W. Rangert-Derolf Å BjÖRkholm M Patterns of survival in multiple myeloma: A population-based study of patients diagnosed in Sweden from 1973 to 2003.J Clin Oncol. 2007; (; 25: 1993–1999. Epub 2007 Apr 9)Crossref PubMed Scopus (256) Google Scholar, 4.Durie B.G. New approaches to treatment for multiple myeloma: durable remission and quality of life as primary goals.Clin Lymphoma Myeloma. 2005; 6: 181-190Abstract Full Text PDF PubMed Scopus (31) Google Scholar], which may explain in part the decreasing suicidal rate seen during later calendar periods [1.Hem E. Loge J.H. Haldorsen T. Ekeberg O. Suicide risk in cancer patients from 1960 to 1999.J Clin Oncol. 2004; 22: 4209-4216Crossref PubMed Scopus (170) Google Scholar]. The prognosis for patients with AML has however not improved to the same extent, particularly not in patients >60 years [5.Derolf ÅR Landgren O Dickman P. Kristinsson S.Y. Björkholm M. Prognosis in acute myeloid leukemia: A population-based study on 5809 patients diagnosed in Sweden 1973-2001. Abstract 1845. Georgia, American Society of Hematology Atlanta2005Google Scholar]. Hopefully, we will be able to improve our understanding of this medical problem among patients with malignant hematological disorders and also better define associated risk factors. Such information is important for hematologists, oncologists and allied health professionals.