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Original Investigation
From the American Head and Neck Society
July 23, 2021

Incidence and Risk of Suicide Among Patients With Head and Neck Cancer in Rural, Urban, and Metropolitan Areas

Author Affiliations
  • 1Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina
  • 2Duke Cancer Institute, Durham, North Carolina
  • 3Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
  • 4Editorial Board Member, JAMA Otolaryngology–Head & Neck Surgery
  • 5Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
  • 6St Louis University School of Medicine, St Louis, Missouri
  • 7Department of Otolaryngology–Head and Neck Surgery, Georgetown University Medical Center, Washington, DC
  • 8Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield
  • 9Simmons Cancer Institute, Springfield, Illinois
  • 10Department of Otolaryngology–Head and Neck Surgery, St Louis University School of Medicine, St Louis, Missouri
  • 11Advanced Health Data Research Institute, St Louis University, St Louis, Missouri
  • 12Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston
  • 13Hollings Cancer Center, Medical University of South Carolina, Charleston
JAMA Otolaryngol Head Neck Surg. Published online July 23, 2021. doi:10.1001/jamaoto.2021.1728
Key Points

Question  Do the incidence and risk of suicide among patients with head and neck cancer differ by rural vs urban or metropolitan residence status?

Findings  In this population-based cross-sectional study, the suicide mortality rate among patients with head and neck cancer was 59, 64, and 127 per 100 000 person-years among residents of metropolitan, urban, and rural counties, respectively. In competing-risk Fine-Gray proportional hazards models accounting for covariates, the suicide risk was nearly 2 times higher for residents of rural counties.

Meaning  This study suggests that suicide incidence is elevated in general among patients with head and neck cancer but is markedly higher for patients living in rural areas.

Abstract

Importance  Patients with head and neck cancer (HNC) are known to be at increased risk of suicide compared with the general population, but there has been insufficient research on whether this risk differs based on patients’ rural, urban, or metropolitan residence status.

Objective  To evaluate whether the risk of suicide among patients with HNC differs by rural vs urban or metropolitan residence status.

Design, Setting, and Participants  This cross-sectional study uses data from the Surveillance, Epidemiology, and End Results database on patients aged 18 to 74 years who received a diagnosis of HNC from January 1, 2000, to December 31, 2016. Statistical analysis was conducted from November 27, 2020, to June 3, 2021.

Exposures  Residence status, assessed using 2013 Rural Urban Continuum Codes.

Main Outcomes and Measures  Death due to suicide was assessed by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes (U03, X60-X84, and Y87.0) and the cause of death recode (50220). Standardized mortality ratios (SMRs) of suicide, assessing the suicide risk among patients with HNC compared with the general population, were calculated. Suicide risk by residence status was compared using Fine-Gray proportional hazards regression models.

Results  Data from 134 510 patients with HNC (101 142 men [75.2%]; mean [SE] age, 57.7 [10.3] years) were analyzed, and 405 suicides were identified. Metropolitan residents composed 86.6% of the sample, urban residents composed 11.7%, and rural residents composed 1.7%. The mortality rate of suicide was 59.2 per 100 000 person-years in metropolitan counties, 64.0 per 100 000 person-years in urban counties, and 126.7 per 100 000 person-years in rural counties. Compared with the general population, the risk of suicide was markedly higher among patients with HNC in metropolitan (SMR, 2.78; 95% CI, 2.49-3.09), urban (SMR, 2.84; 95% CI, 2.13-3.71), and rural (SMR, 5.47; 95% CI, 3.06-9.02) areas. In Fine-Gray competing-risk analyses that adjusted for other covariates, there was no meaningful difference in suicide risk among urban vs metropolitan residents. However, compared with rural residents, residents of urban (subdistribution hazard ratio, 0.52; 95% CI, 0.29-0.94) and metropolitan counties (subdistribution hazard ratio, 0.55; 95% CI, 0.32-0.94) had greatly lower risk of suicide.

Conclusions and Relevance  The findings of this cross-sectional study suggest that suicide risk is elevated in general among patients with HNC but is significantly higher for patients residing in rural areas. Effective suicide prevention strategies in the population of patients with HNC need to account for rural health owing to the high risk of suicide among residents with HNC in rural areas.

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