Oncology: The Suicide Metastasis

1. August 2017
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On average, cancer patients have a 60% higher suicide risk than non-affected persons. Compared to treatment using pharmacotherapy and radiation therapy, psycho-oncology is given low priority. American oncologists want to change that.

“Most doctors do not think about the risk of suicide among cancer patients”, says Mohamed Rahouma from New York Presbyterian Hospital. Working together with colleagues he has now evaluated statistical material and uncovered surprising variations. Rahouma’s aim is to “raise awareness among colleagues”, so that “this catastrophe does not occur with patients in our care”. For this reason he tried to quantify suicide risks.

Bronchial carcinoma associated with high suicide rate

His work was based on data obtained from more than 3.6 million US citizens in the Surveillance, Epidemiology and End Results database (SEER). Within a period of 40 years 6,661 suicides occurred in association with cancer diagnosis. Taking all malignancies into acount, the risk was higher by 60 percent. A previous meta-analysis produced a figure of 55 percent.

Rahouma found significant differences depending on the organ system involved. For prostate and breast cancer the risk of suicide went up by 20 per cent, with colorectal cancer it was even 40 per cent higher. Bronchial carcinomas were significantly out of the norm with a figure of 420 percent.

The reason for this is the subject of mere speculation. In forums we find family and relatives mentioning intolerable pain associated with cancer and asking about potential help with euthanasia. Max Höppner (name changed), who suffered from a prostate-carcinoma, discussed quite openly his suicidal thoughts: “For me it would be a step forward if I could die without pain in the shortest time. It should be possible to enable a patient to die”. He himself is most of all afraid of being unable to bear pain. And a user under the name Unrettbarer [Unsaveable], who suffers from a non-Hodgkin lymphoma, writes: “At the moment I am neither in a state of desperation nor in pain, and for that reason I want to responsibly see to it that I can evade this suicide imposed on me”.

Aside from the fear of pain and nausea the prognosis itself plays a role. Statistical data is easily accessible online. Here are some examples: lung cancer is the second most frequent malignancy in men and the third most common malignancy in women, researchers at the Robert Koch Institute (Germany) report. Five-year or ten-year survival rates remain extremely low when compared to neoplasia, breast and prostate cancer, despite absolutely innovative therapies.

The stage of progress also plays a role

As early as 2010 Anna Bill-Axelson from Sweden’s Karolinska Institute demonstrated that further differences exist depending on the course of progress of the disease. She evaluated several Swedish databases and focused on 77,439 patients with prostate cancer. 128 people took their own lives. Viewed statistically, 85 suicides would be the expected figure.

According to Bill-Axelson, there were no indicators of suicide risk among 22,405 men with stage T1c tumours. Following detection of an elevated PSA level the tumour was diagnosed by way of a fine needle biopsy, but did not cause clinically relevant symptoms. The risk in contrast was more than twice as high in the instance of locally advanced tumour development or when metastases were present. It remains to be seen what sort of relevance these studies have in practice.

Suicide hardly observed in practice

170801_Onkologie_Professor

Professor Dr. Susanne Singer © private

DocCheck discussed this with Professor Dr. Susanne Singer. She has given psychosocial advice to cancer patients and their relatives for twelve years. Singer is currently doing research at the Institute of Medical Biometry, Epidemiology And Computer Science, Johannes Gutenberg University Mainz (Germany). “Researchers have in several countries found an increased suicide risk among cancer patients”, the expert reports. Nevertheless, Singer was not confronted with the subject during her activity as a psycho-oncologist.

“Over this time there were no suicides or suicide attempts among cancer patients”. Singer observed precisely the opposite: “Many people were afraid of dying, but [sic] they did not want die”.

She is not able to exclude that a selective bias is involved: “One sees, first and foremost, people who themselves know that they need support”. Its often also pointed out by the doctor or from relatives. “What I quite often have witnessed however are contemplations of death”, Singer adds. “Clinically defined depression – something which not always picked up in the clinic – may be present here”.

Looking around for support

Jane Walker, a researcher from the Department of Psychiatry at the University of Oxford, revealed as much through a study involving 21,151 cancer patients. Patients with lung cancer (13.1 percent) suffered particularly frequently from major depression, followed by patients with gynecological (10.9 percent), colorectal (7.0 percent) and urogenital tumours (5.6 percent). From among 1,538 patients diagnosed with depression, 1,130 (73 percent) did not receive effective therapy for their psychiatric disorder.

Earlier studies came to a similar conclusion. Of all cancer patients with mental illness, nine per cent visited a psychotherapist within a period of three months, 19 per cent had to wait nine months, and with 11 per cent the wait was even as long as 15 months.

Psycho-oncological co-operation makes sense

Michael Sharpe from Oxford pointed out that targeted measures would very likely work well. Together with colleagues he took 500 cancer patients with good prognoses into a multicentric, randomised, controlled study. With two of every three participants in the specially developed program Depression Care for People with Cancer (DCPC) the severity of their depression decreased by at least 50 percent. Under standard care, this figure was only 17 percent.

Singer sees it as a challenge to inform patients about care offers. It is indeed true that information centres have become better, because cancer centres have to inform patients by following certification guidelines, she says. “But there is still room for improvement”.

 

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