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Suicide Risk in Cancer Patients From 1960 to 1999

From the Department of Behavioral Sciences in Medicine, Ullevål University Hospital, the Cancer Registry of Norway; and Section of Medical Statistics, University of Oslo, Oslo, Norway

Address reprint requests to Erlend Hem, MD, Department of Behavioral Sciences in Medicine, University of Oslo, PO Box 1111 Blindern. NO-0317 Oslo, Norway; e-mail: erlend.hem{at}basalmed.uio.no

	ABSTRACT

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors’ Disclosures of... REFERENCES

 
PURPOSE: Suicide risk is reportedly higher for cancer patients than for the general population, but estimates vary and analyses of trends are few. The aim of the present study was to determine whether cancer patients had a higher suicide risk between 1960 and 1999.

PATIENTS AND METHODS: A cohort comprising patients from the Cancer Registry of Norway 1960 to 1997 was linked to suicide diagnosis in the Register of Deaths at Statistics Norway and observed during 1960 to 1999. The cohort consisted of all cancer patients registered in the Cancer Registry of Norway 1960 to 1997 (N = 490,245 patients with 520,823 cancer diagnoses). Suicide was defined according to death certificates based on the International Classification of Diseases (versions 7, 8, 9, and 10).

RESULTS: During the period, 589 cancer patients (407 males and 182 females) committed suicide. The relative risk was elevated for males and females, with standardized mortality ratios (SMRs) of 1.55 (95% CI, 1.41 to 1.71) and 1.35 (95% CI, 1.17 to 1.56), respectively. Risk was highest in the first months after diagnosis. For both sexes, there was a significant decrease in the relative suicide risk over decades. The risk was markedly increased among male patients with cancer of respiratory organs (SMR, 4.08; 95% CI, 2.96 to 5.47). Otherwise, the SMRs varied from 0.76 to 3.67 across cancer types.

CONCLUSION: Cancer may be a risk factor for suicide, particularly shortly after diagnosis. However, the relative risk gradually decreased during the period 1960 to 1999.

	INTRODUCTION

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Previous studies have demonstrated that the risk of suicide in cancer patients is higher than that for the general population. However, estimates vary, with some stating that the risk is two- to four-fold increased¹ and others stating that it only slightly exceeds that of the general population.²

In a recent review, only six good-quality register studies based on large populations were identified.³ These studies were conducted in Scandinavia, Switzerland, and the United States.^4-9 This reflects the problem of collecting representative samples of suicide and cancer and combining them. The study periods ranged from 7 years (1960 to 1966)⁵ to 30 years (1940 to 1969).⁶ The most recent data come from 1976 to 1987.⁸ Cancer treatment, cancer care, psychosocial support, and social attitudes have changed considerably during the last two decades. Moreover, euthanasia and physician-assisted suicide have been increasingly debated as rational expressions of personal autonomy, not the least among cancer patients. Therefore, new and comprehensive studies of suicide among cancer patients are needed.

The results from the best studies indicate an increased risk among men (standardized mortality ratio [SMR], 1.9 to 2.8), but they are inconsistent as to whether women have an increased risk (SMR, 0.9 to 1.9).^3,10 The results are also inconsistent concerning the duration of increased risk after diagnosis. An excess risk has been reported up to 7 years after diagnosis.⁷ The definition of suicide varies between studies. For example, a nationwide Finnish study included only suicides of people who died from violent causes, thereby excluding suicide by poisoning.⁵ A nationwide Swedish study, the largest study so far, included undetermined or nonclassifiable violent deaths, which accounted for as many as one third of the cases.⁷

Against this background, we wanted to study suicide risk during the last four decades (1960 to 1999) in a nationwide sample of cancer patients, with reference to the characteristics of the patients, the characteristics of the disease, and trends by time periods.

	PATIENTS AND METHODS

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Since 1953, the Cancer Registry of Norway has collected data on the incidence of cancer in the total population. The Cancer Registry receives information on all cancer patients in the population, including site, basis for the diagnosis, histologic grade and type, and the stage of the disease at the time of diagnosis. The registration system is built on multiple reporting from pathology laboratories and hospital departments and compulsory reporting from physicians. The database is updated continually with information on both new cases and previously diagnosed cases. To achieve a high degree of completeness and high data quality, the materials of the Cancer Registry and the Register of Deaths at Statistics Norway are matched. The matching is based on the national 11-digit personal identification number. If information in a death certificate on cancer disease is not found in or is not in accordance with the files of the Cancer Registry, it is submitted to the Cancer Registry and subjected to further inquiry. An evaluation in the 1980s showed a completeness of nearly 100% for all solid tumors but underreporting of cases of leukemia that were not diagnosed in the pathologic laboratories.¹¹ Some reports have been published on the completeness of specific cancer sites.^12,13

The present study comprises cancer diagnoses registered from November 1, 1960, to December 31, 1997. The patients were observed until the occurrence of a new cancer, emigration, death, or December 31, 1999.

For all patients, information on civil status was supplied annually by Statistics Norway. Information on education was taken from population censuses conducted in 1960, 1970, 1980, and 1990.

During the four decades, different versions of the International Classification of Diseases (ICD) were used (ICD-7, ICD-8, ICD-9, and ICD-10). In this study, suicide was defined by the ICD diagnoses of suicide (ie, suicide by poisoning, hanging, drowning, firearms, cutting, jumping from heights, others and unspecified cases, and late sequelae).

On the basis of earlier studies,^7,9 cancer diagnoses were divided into 13 groups (buccal cavity and pharynx; esophagus and stomach; colon and rectum; bronchus, trachea, and lung; breast; female genital organs; prostate; testis and other male genital organs; urinary system; brain; skin; lymphatic and hematopoietic tissue; and others including synchronous cancers). Age was divided into the following six groups: children (0 to 14 years), adolescents (15 to 24 years), adults (25 to 54 years), middle-aged (55 to 64 years), older middle-aged (65 to 74 years), and old ( 75 years).

The entire database consisted of 643 suicides. Forty-four people were excluded because cancer was based on death certificate only with no further information available, and 10 people were excluded because cancer was an incidental finding at autopsy. Therefore, the cohort consisted of 589 cancer patients who committed suicide. In total, 490,245 cancer patients were registered comprising 520,823 cancer diagnoses and 2,536,152 person-years.

The observed number of cases was compared with the expected number of deaths, and SMRs were computed by calculating the ratio of observed to expected cases. Ninety-five percent CIs were computed by assuming that the observed deaths followed a Poisson distribution. The reference rates were based on the suicide rates in each sex in the Norwegian population for periods of every 5 years from 1956 to 1999 in 5-year age groups beginning with age 0 years and ending with age 90+ years. The observed person-years of cancer patients according to time and age were multiplied with the reference suicide rate to estimate the expected number.

² tests were performed to test for heterogeneity and trends in SMRs.¹⁴ P < .05 was considered statistically significant.

	RESULTS

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There were 589 persons (407 males and 182 women) registered with a cancer diagnosis who committed suicide between 1960 and 1999. The relative suicide risk was elevated for both males and females, with SMRs of 1.55 (95% CI, 1.41 to 1.71) and 1.35 (95% CI, 1.17 to 1.56), respectively (P = .13; Table 1). The relative risk was markedly elevated for both sexes the first months after diagnosis and significantly decreased over subsequent months (P < .001 and P = .005, respectively; Table 2).

	DISCUSSION

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The study has important clinical implications. First, cancer is a risk factor for suicide, and the risk increases with disease severity. Second, the risk is highest shortly after the diagnosis has been made, but for some cancer types, the risk was increased for more than 5 years after diagnosis. Third, the suicide risk has decreased since the 1960s but was still raised during the 1990s. Fourth, men have a higher suicide risk than women.

The male suicide risk results from our cohort are somewhat lower than the results from the best previous studies (SMR, 1.6 v 1.9 to 2.8, respectively).³ Previous results have been inconsistent concerning women, but in our study, the female suicide risk was elevated. Direct comparisons with previous studies are difficult, however, because of different definitions of suicide. A higher suicide risk for male cancer patients compared with females is in agreement with all other studies. This may reflect, in part, the belief that men adapt less well than women to a cancer diagnosis.

There has been considerable speculation over why some patients with certain cancer types seem to carry a higher suicide risk than others. For example, it has been suggested that certain cancer types may have more profound effects on quality of life and induce stronger degrees of anxiety or fear because of symbolic values, cognitive functions, change in body image, or difficulties of speech, breathing, or eating.^7,15,16 However, the present study shows that almost all cancers entail a slightly elevated suicide risk, but cancers in respiratory organs among men seem to be of particular concern. This finding carries an important clinical message. Moreover, a consistent finding in the literature, as well as in the present study, is that the risk increases with disease severity.

The suicide risk declined as time since diagnosis increased. This may be explained by the natural course of the cancer disease and the gradual adaptation to having or having had a life-threatening disease. The number of patients with the poorest prognosis for survival will be highest in the first years after diagnosis, and these patients may also be the most vulnerable to suicide. Eventually, surviving patients will be cured, and 5 years after diagnosis, the risk should be about the same as for the general population.⁷ However, because cancer is often a chronic disease, clinicians’ alertness to depressive symptoms and suicidality should not be restricted to only the first months after diagnosis. This is of special relevance for breast cancer, which has an unpredictable course. In the same vein, a study of all suicides in Finland in 1987 found that 4.3% had cancer, and nearly half of them were in remission at the time of the suicide.¹⁷

Major depression is a psychiatric illness most commonly associated with suicide, and depressive symptoms are prevalent among cancer patients. Unfortunately, we have no data on depression in this sample. It is hypothesized that improved treatment of depression, including the use of antidepressants, has reduced the suicide rate in the Nordic countries.¹⁸ Improved treatment and increased focus on depressive symptoms among cancer patients may also explain the decreasing suicide risk in the study sample.¹⁹ Although the treatment of and attitude toward mental illness generally have improved in Norway during the last years, there has been a particularly strong emphasis on openness about mental suffering and psychosocial support in cancer care. The decline in suicide risk during the four decades may also reflect improvements in treatment, including less-mutilating surgical interventions, improved medical outcomes, and psychosocial support.²⁰ Moreover, in Scandinavia, palliative care has markedly improved during the last years, particularly in Norway, and the sales of morphine doubled during the years of 1988 to 1998 (defined daily dose per 1,000 inhabitants per day). Additionally, oncologic practice in the same period has probably become more patient oriented, as illustrated by the introduction of a compulsory training course in communication skills in oncology.

There are some important methodologic issues concerning these kinds of studies. The risk estimates are relative (not absolute) figures. That is, because suicide risk is higher in the older population in Norway, the relative suicide risk might be lower for the old cancer patients than for the younger age groups. We expected that the suicide risk would be elevated among young and middle-aged persons because it may be easier to accept cancer at advanced ages. Psychological distress and perceived loss are generally higher among younger cancer patients. However, the risk may also be elevated in old age. A recent Swedish study found that cancer was associated with increased risk of suicide among those aged 65 years and over.²¹ Furthermore, the general suicide rate in Norway was doubled from approximately 8 to 16 per 100,000 people per year from 1970 to 1990. Hence, the expected number of suicides in this study differs significantly over the decades. In Denmark, an increasing suicide risk among cancer patients was reported during 1971 to 1986, but no significant increase in the general suicide rate occurred.⁹

The follow-up period for each patient is important. If the follow-up period is unlimited, the number of person-years will increase substantially in the last decades, and the risk estimates will be artificially low. However, when restricting the follow-up time to 2 years after diagnosis, the same pattern is shown for age, civil status, and education.

It is often claimed that suicide among cancer patients is underreported.² The general problem concerning validity of suicide statistics is well known. However, are there any systematic differences between cancer patients and the general population in reporting suicide as the cause of death? On one side, cancer patients are in contact with the healthcare system and are often closely observed. This may imply that suicidal behavior is recognized more often in these patients. On the other side, physicians may be reluctant to classify an overdose of analgesics and sedatives as suicide in this group.⁷ The lower percentage of female cancer patients in the present study who committed suicide by poisoning may support such an interpretation. However, no such differences were found for the males. Combined with the small absolute number of suicide among female cancer patients, we believe that our results are not biased by misclassification of suicides by poisoning as accidental overdoses. Changes in registration procedures may also complicate the interpretation of suicide rates during the study period.²² However, we have no reason to believe that such changes affect cancer patients and the general population differently, and the reliability of the Norwegian suicide statistics is generally considered as good.²³ In conclusion, although there is no evidence for underreporting of suicides among cancer patients in the present study, it cannot be fully ruled out.

Some individuals ignore cancer symptoms and delay seeking help. Sometimes, these patients are admitted to hospitals with late-stage cancers. It may be theorized that some of those individuals with such deviant illness behavior commit suicide and, therefore, would not have been registered in our database. However, it is uncertain whether such suicides would be a result of the disease, and, in any case, the number would be low and not influence the results.

Bronchus, trachea, and lung cancers carried the highest suicide risks among men, whereas cancers in the buccal cavity and pharynx carried the highest risk among women. These cancer types are associated with smoking and, in part, alcohol abuse. These factors are interrelated with depressive disorders. That is, people who smoke often also consume alcohol and vice versa, and those who are depressed have higher rates of both alcohol misuse and smoking, as well as greater difficulty in quitting.^16,24,25 The relation of smoking and alcohol abuse to suicidal behavior may, in part, confound the linkage of these lifestyle-associated cancers to high suicide risk. Hence, the high relative suicide risk in some cancer sites in the present and previous studies may indicate a confounding effect.

Differences between population-based studies in several countries may derive from differences in sociocultural backgrounds, cancer care systems, patient characteristics in relation to survival, and suicide rates within the general population in these countries.²⁶ For example, the suicide rates differ significantly between countries and by time. The suicide rates in Norway, Sweden, and Denmark differed around 1960, with the lowest rate in Norway. However, during the observation period, the suicide rates gradually became quite similar (12 to 14 per 100,000 inhabitants), whereas the rate in a neighboring country, Finland, was nearly twice as high (24 per 100,000 inhabitants). In the United States, between 1981 and 1998, the age-adjusted suicide rate decreased by 9.3%, from 11.5 suicides per 100,000 persons to 10.4 suicides per 100,000 persons.¹ Additionally, there are substantial similarities in cancer care in Western Europe and North America. Hence, the findings of this study may be quite widely generalized.

Depressive symptoms have been found to be equally common among cancer suicides and other suicides.²⁷ However, few data explain why some cancer patients suffering from major depression have suicidal ideation, whereas others do not. Some findings suggest that severe depression, pain, and poor physical functioning are important indicators of suicidal ideation among cancer patients.^28,29

The suicide of a person suffering from cancer may be regarded as a rational alternative to the prolonged physical and mental distress caused by the disease. However, as in the present study, remarkably few cancer patients commit suicide, even at the terminal stage.²⁷ In an Italian study, only 0.22% of all deaths of cancer patients were a result of suicide.³⁰ At the same time, most patients with cancer do not develop major depression, suggesting that cancer is a risk factor, not a mandate, for depression.³¹ Depression rates among terminally ill patients requesting physician-assisted suicide and euthanasia are particularly high.³² Accordingly, cancer is the most prevalent diagnosis for patients who end their lives in such ways.^33,34

More than 60 different risk factors for suicide are described, including physical illness.³⁵ Therefore, suicide is a multidetermined event, and the search for a single explanatory factor is too simplistic. Hence, medical illness is unlikely to be a sole determinant of suicide but may be regarded as a predominant factor.³⁶

Frank discussion of suicidal ideation with cancer patients is important. Although clinicians often fear such discussion, there is no evidence that talking about suicide encourages people to attempt suicide. Identifying and treating depression among cancer patients has been shown to decrease morbidity and mortality.³⁷ It is particularly important to evaluate the presence of hopelessness, which may be a stronger predictor of suicidal risk than depression itself.³⁸ Patients’ existential suffering may be a difficult topic to address.^39,40 The ability of physicians to communicate openly and clearly with their patients about these difficult issues should be a part of the physician’s toolbox.

	Authors’ Disclosures of Potential Conflicts of Interest

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors’ Disclosures of... REFERENCES

 
The authors indicated no potential conflicts of interest.

	Acknowledgment

 
We are grateful to Jan Ivar Martinsen for computational assistance and data preparation.

	NOTES

 
Supported in part by grants from the Norwegian Cancer Society (Project No. E03018/001), the Almus Foundation, Einar and Kitty Unsgaard’s Foundation, and Johanne and Einar Eilertsen’s Foundation.

Presented, in part, at the 8th International Conference for European Association of Palliative Care, den Haag, Holland, April 2-5, 2003, and at the 22nd World Congress of the International Association for Suicide Prevention, Stockholm, Sweden, September 10-14, 2003. After submission of the manuscript, the paper has also been presented, in part, at the 25th European Conference on Psychosomatic Research, Berlin, Germany, June 23-26, 2004.

Authors’ disclosures of potential conflicts of interest are found at the end of this article.

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Submitted February 6, 2004; accepted July 24, 2004.

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