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Originally published as JCO Early Release 10.1200/JCO.2008.18.3129 on August 11 2008 © 2008 American Society of Clinical Oncology.
Suicidal Thoughts and Actions in Cancer Patients: The Time for Exploration Is Now
Internal Medicine, Psychiatry, and Medical Humanities, Center for Ethics, Humanities, and Palliative Care, University of Rochester Medical Center, Rochester, NY Three studies in this month's Journal of Clinical Oncology 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 al1 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 Denmark2; respiratory and oropharyngeal cancers in Norway3; 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 al5 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 al6 gives an enticing, though very small glimpse at what might lead up to such tragic outcomes. These researchers surveyed consecutive patients attending an outpatient clinic of a regional cancer centre in Edinburgh, United Kingdom, using the Patient Health Questionnaire 9 instrument with particular attention to item 9, which asked about "thoughts that you would be better off dead, or of hurting yourself in some way" in the past 2 weeks. Patients also completed screening instruments for anxiety and depression (Hospital Anxiety and Depression Scale) and pain (European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire C30). Some patients (7.8%) had a positive response—defined as having several days or more of thoughts they would be better off dead or of hurting themselves within the 2 weeks before the appointment. The multivariate logistic regression analysis showed that these responses were strongly associated with significant emotional distress and with substantial pain, and also weakly associated with increasing age. The simultaneous presence of both emotional distress and pain had the strongest association with these suicidal thoughts by both younger and older patients with cancer. Thoughts about death and the possibility of suicide are probably common in terminally ill patients with cancer (as well as with other serious illnesses). In a survey of 988 terminally ill outpatients, Emanuel et al7 found that 60% supported legal access to a physician-assisted death, and 10% were seriously pursuing that option. In another survey of 92 terminally ill inpatients at Calvary Hospice, Breitbart et al8 found that 17% had a high desire for physician-assisted death though none actively pursued it. Of importance in the latter study is a high incidence of clinical depression in those who wanted this option (half were depressed), and also a relatively high incidence of hopelessness (which did not fully overlap with depression.) In Oregon, where physician-assisted death has been legalized for terminally ill patients (subject to safeguards), it has accounted for approximately one in 1,000 deaths from all causes each year for over 10 years. A study by Tolle et al9 showed that in Oregon, one of 50 terminally ill patients talks to their doctors about assisted death and one in six talks to family members, suggesting that in a relatively receptive environment there is much conversation about these issues and relatively little action. What is interesting and potentially important about the studies in this issue of JCO is that these thoughts about suicide and the associated risk factors that are relatively well known for terminally ill patients may be just as important for those patients with cancer who are survivors or are living with the disease. There are important research and clinical questions raised by these studies which probably capture only a small fraction of the phenomenon. The reported cases of suicide in the study by Miller et al5 focused primarily on violent, clearly defined acts, but many seriously ill patients with cancer have access to potentially lethal medication that they could take in overdose on their own. These acts often go unreported (why put the family through additional trauma?) or unexplored (why go looking for trouble?) by the certifying physician who can easily cite the underlying malignancy as the cause of death. Furthermore, the rate of physician-assisted death in Oregon (one in 1,000 deaths) is higher that the rate of suicides reported in these two studies, and the rate of the secret practice of physician-assisted death in the rest of the country may be substantially higher than in Oregon (though such acts are hard to accurately estimate because of their illegality).10 Acts with physician participation should probably be viewed differently than the kinds of violent suicides reported in these studies, though both are not well studied and are subject to similar risks and pitfalls. The key point is that the studies in this issue of JCO are probably capturing a small proportion of a much larger and more complex phenomenon. There is a need to unbundle and study the range of suicidal thoughts, intentions, and actions that many patients with cancer and other serious medical illnesses experience. Because there are issues of social stigma as well as illegality involved, research will require very special safeguards and protections for all involved. Research will often require a mix of both quantitative and qualitative measures because in many circumstances we do not even know the best questions. For example, common symptoms of all seriously ill patients (weight loss, sleep disturbance, thoughts about death, worry about the future) may lead to an overestimation of the frequency of clinical depression using usual depression and hopelessness scales.11 Qualitative studies will be needed to deepen our understanding of the range of thoughts, feelings, hopes, and fears present in many seriously ill patients, so we can better distinguish clinical depression and anxiety that might be amenable to medical treatment from the range of normal sadness and fear that can be acknowledged and explored, but not necessarily "treated". There are risks of both overnormalizing (missing the opportunity to lessen suffering and even prevent suicide) and of overpathologizing (increasing suffering and medicalizing normal processes), so new more sophisticated clinical and research models may be needed. Based on my clinical experience in palliative care, there are many related areas that need both study and clinical attention, including the following. Many people with advanced cancer are both fearful of death itself and also fearful about how they will die. Some of these patients may contemplate the possibility of future suicide, and most will talk about these issues if given an invitation in a safe environment. Given the opportunity, some of these patients will want to know what their options might be if their suffering becomes unacceptable in the future. When faced with such inquiries, clinicians should talk about how they can and cannot help in the future. Many patients are profoundly reassured by their clinician's willingness to engage in this conversation, and are appreciative of any commitment to face the unknown together.12 The incidence of under-recognized and undertreated depression, anxiety, delirium, and pain is very high in patients with cancer at all stages of treatment. Systematic screening and treatment are essential, as are approaches that include formal palliative care or psychiatric consultation for more challenging cases. It is important to ask about suicidal thoughts and intent regularly, especially at times of transition when disease is worsening, symptoms are increasing, or the patient is entering a more serious phase of illness. Creating an environment where these issues can be openly explored without being judged is critical. Ask about risk factors for suicide (prior attempts, clinical depression, panic disorder, substance abuse history), and be aware of conditions where risk is increased (pancreatic cancer, treatment with interferon). If a patient is considering any potentially life-ending act, whether it be stopping potentially effective treatment, stopping eating and drinking, or contemplating physician-assisted suicide, explore the underlying meaning of the request and look for confounding depression, anxiety, and pain before responding.13 Lessening suffering of seriously ill patients through the diligent application of palliative measures and alleviating their aloneness and despair by maintaining an open, committed, receptive relationship may be the most important preventive measures with regard to suicide. AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Although all authors completed the disclosure declaration, the following author(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a "U" are those for which no compensation was received; those relationships marked with a "C" were compensated. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors. Employment or Leadership Position: Timothy E. Quill, American Academy of Hospice and Palliative Medicine (U), Death with Dignity National Center (U) Consultant or Advisory Role: None Stock Ownership: None Honoraria: None Research Funding: None Expert Testimony: None Other Remuneration: None NOTES published online ahead of print at www.jco.org on August 11, 2008 REFERENCES
1. Misono S, Weiss NS, Fann JR, et al: Incidence of suicide in persons with cancer. J Clin Oncol doi:10.1200/JCO.2007.13.8941 [epub ahead of print on August 11, 2008] 2. Yousaf U, Christensen ML, Engholm G, et al: Suicides among Danish patients with cancer. Br J Cancer 92:995-1000, 2005[CrossRef][Medline] 3. Hem E, Loge JH, Haldorsen T, et al: Suicide risk in cancer patients from 1960-1999. J Clin Oncol 22:4209-4216, 2004 4. Bjorkenstam C, Edberg A, Ayoubi S, et al: Are cancer patients at higher suicide risk than the general population? Scand J Public Health 33:208-214, 2005 5. Miller M, Mogun H, Azrael D, et al: Cancer and the risk of suicide in older Americans. J Clin Oncol doi:10.1200/JCO.2007.14.3990 [epub ahead of print on August 11, 2008] 6. Walker J, Waters RA, Murray G, et al: Better off dead: Suicidal thoughts in cancer patients. J Clin Oncol doi:10.1200/JCO.2007.11.8844 [epub ahead of print on August 11, 2008] 7. Emanuel EJ, Fairclough DL, Emanuel LL: Attitudes and desires related to euthanasia and physician-assisted suicide among terminally ill patients and their caregivers. JAMA 284:2460-2468, 2000 8. Breitbart W, Rosenfeld BD, Pessin H, et al: Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. JAMA 284:2907-2911, 2000 9. Tolle SW, Tilden VP, Drach LL, et al: Characteristics and proportion of dying Oregonians who personally consider physician-assisted suicide. J Clin Ethics 15:111-118, 2004[Medline] 10. Meier DE, Emmons C, Wallenstein S, et al: A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med 338:1193-1201, 1998 11. Block SD: Assessing and managing depression in the terminally ill patient: ACP-ASIM End-of-Life Care Consensus Panel. Ann Intern Med 132:209-218, 2000 12. Quill TE, Cassel CK: Nonabandonment: A central obligation for physicians. Ann Intern Med 122:368-374, 1995 13. Quill TE: Doctor, I want to die: Will you help me? JAMA 270:870-873, 1993
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Copyright © 2008 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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