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Journal of Clinical Oncology, Vol 25, No 6 (February 20), 2007: pp. 733-734 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.09.4797
In ReplyDana-Farber Cancer Institute, Harvard Medical School, Boston, MA
Suffolk University, Boston, MA We read with great interest the correspondence from Dr Howard et al concerning our report of suicidal ideation in adult survivors of childhood cancers.1 We agree their report of excess risk of suicide among childhood cancer patients in the Surveillance, Epidemiology, and End Results (SEER) registries is consistent with our study, and believe it substantiates and extends our findings in important ways. As both Howard et al and Hawkins et al note, the epidemiological studies of suicide in cancer patients we cited did not provide separate risk estimates for pediatric patients—something now available in Howard et al's correspondence. Howard et al report excess risk of completed suicide in a large population-based cohort of survivors, complementing our report of suicidal ideation and attempt in a very different cohort of patients, namely those seeking care in a survivor clinic. They found risk was higher among those treated later in childhood, and suicide typically occurred in young adults (median age, 26.8 years). In contrast, Hawkins et al cite several previous studies of childhood cancer survivors that did not find elevated risk of suicide. Differences in findings could be explained by the fact that these studies had smaller samples, did not all include subjects diagnosed at older ages2-4 and may not have followed them as far into adulthood. In addition, several of the studies3-6 included patients treated between 1940 and 1970, when cancer treatments were less effective and relapses more common.3,5,6 Mortality outcomes from earlier treatment eras may not generalize to cohorts treated more recently, as Hawkins et al previously noted,2 since a decrease in risk of cancer-related mortality may allow other competing risks to emerge. Although Howard et al report no increased risk of suicide in "patients initially treated with [any] radiation," we do not see this as inconsistent with our finding that cranial radiation therapy was associated with suicidal ideation because cranial radiation in childhood is associated with a specific pattern of cognitive7 and educational8 sequelae not associated with other forms of radiotherapy. We hypothesize it is these late effects of CNS therapy that are associated with suicide ideation, a hypothesis we are currently examining in an analysis of data from the Childhood Cancer Survivor Study.9 The report of increased risk of completed suicide in the SEER data complements our findings on rates of suicide ideation. While suicide ideation and attempt are highly correlated with completed suicide,10 there are significant differences between these three variables. Important differences in risk factors for suicide attempt and completion are well-established,11 and some investigators have argued they should be conceptually and methodologically distinguished.12 Because pediatric cancer patients face a life-threatening condition during their formative years, we could reasonably hypothesize they would be more likely to contemplate death and dying later in life, but that this might not reflect true suicidal ideation or intent. Sadly, the results reported by Howard et al disabuse us of this hypothesis, demonstrating that increased risk of suicidality in this population is not limited to ideation but extends to completed suicide. Fortunately, very few childhood cancer survivors commit suicide, but the increased risk attributable to childhood cancer, and the presence of a small but significant minority of survivors (12.8%) with suicidal symptoms identified in our study, point to the critical need to address psychological outcomes among childhood cancer survivors. Future research in this area should focus on identifying risk factors for suicidality that may be used to guide the development of appropriate methods of assessment and intervention. 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. Robertson CM, Hawkins MM, Kingston JE: Late deaths and survival after childhood cancer: Implications for cure. BMJ 309:162-166, 1994 3. Hawkins MM, Kingston JE, Kinnier Wilson LM: Late deaths after treatment for childhood cancer. Arch Dis Child 65:1356-1363, 1990[Abstract] 4. Cardous-Ubbink MC, Heinen RC, Langeveld NE, et al: Long-term cause-specific mortality among five-year survivors of childhood cancer. Pediatr Blood Cancer 42:563-573, 2004[CrossRef][Medline] 5. Möller TR, Garwicz S, Neglia JP, et al: Decreasing late mortality among five-year survivors of cancer in childhood and adolescence: A population-based study in the Nordic countries J Clin Oncol 19:3173-3181, 2001 6. Hudson MM, Jones D, Boyett J, et al: Late mortality of long-term survivors of childhood cancer. J Clin Oncol 15:2205-2213, 1997 7. Waber DP, Carpentieri SC, Klar N, et al: Cognitive sequelae in children treated for acute lymphoblastic leukemia with dexamethasone or prednisone. J Pediatr Hematol Oncol 22:206-213, 2000[CrossRef][Medline] 8. Mitby PA, Robison LL, Whitton JA, et al: Utilization of special education services and educational attainment among long-term survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. Cancer 97:1115-1126, 2003[CrossRef][Medline] 9. Robison LL, Mertens AC, Boice JD, et al: Study design and cohort characteristics of the Childhood Cancer Survivor Study: A multi-institutional collaborative project. Med Pediatr Oncol 38:229-239, 2002[CrossRef][Medline] 10. Maris, RW: The relationship of nonfatal suicide attempts to completed suicide, in Maris RW, Berman AL, Maltsberger JT, et al (eds): Assessment and Prediction of Suicide. New York, Guilford Press, 1992, pp 362-380 11. Gaynes BN, West SL, Ford CA, et al: Screening for suicide risk in adults: A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 140:822-835 12. Carlson GA, Cantwell DP: Suicidal behavior and depression in children and adolescents. J Am Acad Child Adolesc Psychiatry 21:361-368 Related Correspondence
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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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