Suicidal Thoughts and Actions in Cancer Patients: The Time for Exploration Is Now
Authors: Timothy E. Quill
Journal: Journal of Clinical Oncology (2008)

Three studies in this month’sJournalofClinicalOncology explore different aspects of the potential risk of suicide in patients with cancer. Most prior studies on this subject focused primarily on terminally ill patients, but these studies included broader populations of patients with cancer more reflective of general oncology practice, including patients likely to be long-term survivors, those whose cancer is more of a chronic illness, as well as those who are terminally ill. The first study by Misono et al 1 used two large databases (the Surveillance, Epidemiology, and End Results program of the National Cancer Institute and the National Center for Health Statistics) to compare the incidence of suicide in cancer patients with an age-, sex-, and race-adjusted cohort of the general population over a 30-year period. They found the incidence of suicide in patients with cancer was almost twice the general population, and that higher rates were found in those with male sex, white race, and older age. They also found that rates of suicide varied with site of cancer, with highest rates found in patients with lung cancer, followed by stomach, oropharyngeal, and laryngeal, in that order. The demographic risk factors are consistent with other studies, though the site-specific risks are inconsistent with prior studies conducted primarily in Europe, which showed high rates of suicide with respiratory and breast cancers in Denmark 2 ; respiratory and oropharyngeal cancers in Norway 3 ; and esophageal, pancreatic, and respiratory cancers in Sweden. 4 Data about comorbid medical and psychiatric conditions, extent of disease, prognosis, functional status, or symptom burden were unavailable. The second study by Miller et al 5 also used another large database (the New Jersey Pharmaceutical Assistance Program for the Aged and Disabled and the Medicare database) to identify 128 cases of suicide (reported as the cause of death by the New Jersey Department of Vital Statistics) and 10 living controls for each case matched by age, sex, and race. In this analysis, the only comorbid medical condition associated with suicide was cancer. Suicide was also associated with the diagnoses of affective or anxiety/personality disorders, and with treatment with antidepressants or opioid analgesics. The reported suicides tended to be violent (the majority involved firearms or hanging) and a relatively small percent (16% overall and 11% of patients with cancer) involved self-poisoning with drugs other than opioids. Of potential clinical importance, the majority had visited a physician within 1 month before the suicide, and 25% visited within their last week. One might be tempted to infer a relatively high symptom burden by the increased presence of opioids in the suicide group, but we unfortunately have little information about either psychiatric or palliative treatment in either of these groups other than what can be indirectly inferred from a pharmaceutical database. The third study by Walker et al 6 gives an enticing, though very small glimpse at what might lead up to such tragic outcomes. These