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Journal of Clinical Oncology, Vol 25, No 6 (February 20), 2007: pp. 732-733 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.10.0990
Suicide Risk in Childhood Cancer SurvivorsSchool of Social Work, University of Southern California, Los Angeles, CA To the Editor: Suicide is a major cause of death for persons of all ages in the United States and around the world, and its association with both physical and emotional distress is well-documented. In a recent issue of Journal of Clinical Oncology, Dr Recklitis et al1 suggest that when viewed in the context of population-based studies of suicide, adult survivors of childhood cancer have an elevated risk for suicidality. Suicidal ideation is a serious health problem and a key indicator of possible major depression.2 However, few cancer patients and off-treatment survivors are routinely screened for depression, let alone suicide risk. For those screened, the majority do not receive guideline-based assessment, and even fewer receive guideline-based depression care management.3-5 This condition is troubling in that effective treatments exist and that patients can choose from these if properly and rightfully informed.3 The recent report on suicidality in childhood cancer survivors offers a critical focus on yet another population that is not receiving care on evidence-based guidelines. As social scientists, we appreciate the methodological rigor and excellent reporting by Recklitis et al. As a cancer survivor and former oncology social worker, however, I (B.J.Z.) struggled to understand my initial distressing reaction to their report. First, I was struck by the literally calculating and disembodying statistical presentation of suicidal risk in this report. It reminded me of the anonymous motto I once kept above my computer: "Statistics are people with their tears wiped away." I also wondered about the 29 young adult survivors in the study whose responses led the investigators to conclude that they were at risk for suicide. Have any of those survivors in fact committed suicide since the completion of data collection? What actions, if any, were initiated on their behalf? I can only assume that the routine psychological screening at the multidisciplinary cancer survivor clinic where the survey data collection occurred detected respondents who were at risk for suicide and resulted in evidence-based care. A nice test of inter-rater reliability would have been a comparison to see if the same 29 respondents who indicated suicidality in their survey also were assessed and identified by clinicians as demonstrating indicators of suicide risk: ideation, a plan, and access to means for carrying out their plan. Epidemiological survey research and a clinical encounter represent two different ways of knowing and accumulating information about a person, a situation, and a phenomenon. Each way has the potential to contribute to suicide assessment and an understanding of "truth," but neither represents the whole truth. While the story told by Recklitis et al offers important knowledge regarding risk factors and suicide in childhood cancer survivors, it does not capture the emotional, cognitive, and what Shea6 refers to as the "nightmarish" aspects of suicide as a social phenomenon and individual experience. Suicide is a complex and deeply personal phenomenon with behaviors and aspects that vary from person to person. Even Recklitis et al,1 who used just two items to assess suicidal ideation and past attempts, acknowledged the viewpoint that "adequate assessment of suicidal ideation requires multiple questions reflecting a range of intensity and symptoms." In The Practical Art of Suicide Assessment, Shea6 suggests that suicide assessment comprises three tasks: gathering information related to risk factors, assessing ideation and plans for carrying out suicide, and decision making with regard to action. He also tells us that individuals' responses to questions about suicide ideation are context specific, depending on setting, who is asking the questions, and even the time when they are asked. Thus, what an individual reveals about his/her thoughts of suicide and even past attempts is specific to the situation. For example, some investigators have used approaches to assess ideation or past attempts in a way that distinguishes lethal attempts from cries for help.7 In this way, investigators acknowledge that all suicide attempts are not alike and are somehow related to the emotions, cognitions, and meanings that individuals attribute to their condition or situation. As for assessing suicidal ideation, information-collecting methods must extend beyond simple endorsements of one or two items about thoughts of killing oneself and more to a deeper appreciation of ideation as it may indicate depression or reflect an expression of some inner emotional or outer physical pain and suffering. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The authors indicated no potential conflicts of interest. REFERENCES
1. Recklitis CJ, Lockwood RA, Rothwell MA, et al: Suicidal ideation and attempts in adult survivors of childhood cancer. J Clin Oncol 24:3852-3857, 2006 2. Ell K, Sanchez K, Vourlekis B: Depression, receipt of depression care, and correlates of depression among low-income women with breast or gynecological cancer. J Clin Oncol 23:3052-3060, 2005 3. Ell K, Quon B: Depression management in cancer patients. Psychiatric Times 23:25-28, 2005 4. Passik SD, Dugan W, McDonald MV: Oncologists' recognition of depression in their patients with cancer. J Clin Oncol 16:1594-1600, 1998 5. Ashbury FD, Madlensky L, Raich P: Antidepressant prescribing in community cancer care. Support Care Cancer 11:278-285, 2003[Medline] 6. Shea SC: The Practical Art of Suicide Assessment. Hoboken, NJ, John Wiley & Sons Inc, 2002, pp 3856 7. Kessler RC, Berglund P, Borges G, et al: Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990-1992 to 2001-2003. JAMA 293:2487-2495, 2005 Related Article
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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