Reference population is the general US population in corresponding age groups. SMR indicates standardized mortality ratio. Error bars indicate 95% CIs.
David Kam, Andrew Salib, George Gorgy, Tapan D. Patel, Eric T. Carniol, Jean Anderson Eloy, Soly Baredes, Richard Chan Woo Park. Incidence of Suicide in Patients With Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg. 2015;141(12):1075–1081. doi:10.1001/jamaoto.2015.2480
Suicide rates among patients with cancer in the US are significantly higher than those of the general population. To our knowledge, large cohort studies examining suicide rates among patients with head and neck cancer have not been performed.
To identify incidence rate, trends, and risk factors of suicide in patients with cancer of the head and neck.
Design, Setting, and Participants
This was a retrospective cohort study of geographic areas served by the Surveillance, Epidemiology, and End Results (SEER) program. In total, 350 413 cases of patients with head and neck cancer were recorded within the SEER registry between 1973 and 2011. Data analyses were performed in 2014. Incidence data were calculated from the subset of that population that had the cause of death category coded as “suicide and self-inflicted injury.”
Patients diagnosed as having a primary cancer of the head and neck region.
Main Outcomes and Measures
Influence of demographic factors, anatomic site of tumor, disease stage, and time since diagnosis on risk for suicide.
Among 350 413 SEER registry patients with head and neck cancer, observed for 2 263 376 person-years, 857 suicides were identified with an age-, sex-, and race-adjusted suicide rate of 37.9/100 000 person-years. In contrast, the US general population suicide rate was 11.8 per 100 000 person-years. Suicide rates were higher in those treated with radiation alone (standardized mortality ratio [SMR], 5.12; 95% CI, 3.83-6.41) compared with those treated with surgery alone (SMR, 2.57; 95% CI, 1.66-3.49). The highest suicide risk was seen in patients with cancers of the hypopharynx (SMR, 13.91; 95% CI, 11.78-16.03) and larynx (SMR, 5.48; 95% CI, 4.14-6.81).
Conclusions and Relevance
Patients with head and neck cancer have more than 3 times the incidence of suicide compared with the general US population. Furthermore, suicide rates were highest among those with cancers of the larynx and hypopharynx.
Suicide is a significant cause of death in most Western countries and is the 10th leading cause of death in the United States.1 In patients with cancer, the risk for suicide is even higher; patients with cancer in the United States have nearly twice the incidence of suicide as the US general population.2,3 While affective illness and alcoholism are the most important determinants of suicide in the physically healthy population, vulnerability to suicide in patients with cancer is influenced by a number of other factors, including psychosocial and psychosomatic effects of advanced illness, pain, organic mental syndromes, and preexisting psychopathologic abnormalities.4 Most recently, Misono et al2 used the Surveillance, Epidemiology, and End Results (SEER) database to evaluate the incidence of suicide in persons with any type of cancer. Using data up to 2002, they found that cancers of the lung and bronchus, stomach, oral cavity and pharynx, and larynx were associated with the highest rates of suicide.
Despite the strong evidence of increased risk of suicide among patients diagnosed as having cancer, to our knowledge, an in-depth analysis of suicide in patients with head and neck cancer has yet to be performed. Both the pathologic findings and the treatment of head and neck cancers, which includes radiation, surgery, and chemotherapy, can have adverse effects on patients’ daily quality of life (QOL). Distortions of voice, hearing, taste, chewing, swallowing, and breathing may produce psychological distress for decades after successful treatment. New treatment modalities for head and neck cancer have been introduced and popularized since 2002, including transoral robotic surgery (TORS) and intensity-modulated radiation therapy (IMRT). To our knowledge, the impact of these techniques on suicide risk of patients with head and neck cancer has not been investigated.
In this study, we examined suicide rates exclusively among patients with cancers of the head and neck and included more recent data from the SEER database. Suicide rates were calculated and compared with the rates of suicide in the US general population. Rates were adjusted for patient demographics and disease characteristics to identify risk factors for suicide in this patient population.
The SEER Program was used to identify patients with cancer in the head and neck region (nasal cavity, nasal sinuses, nasopharynx, oral cavity, oropharynx, salivary glands, hypopharynx, larynx, and thyroid gland). SEER collects cancer incidence and survival data from multiple cancer registries throughout the United States. These registries cover approximately 28% of the US population, with appropriate representation of most ethnicities in the United States. The SEER database contains patients’ demographics (age, sex, race, marital status), cancer staging, course of treatment, follow-up status, and mortality data, which allows for various classifications and analyses of the survival data.5 The US general population mortality data for 1973 to 2011 was accessed through the SEER program, which obtains data from the US Census Bureau.
This study did not involve interaction with human participants or the use of any personal identifying information. Hence, institutional review board approval was not required by Rutgers New Jersey Medical School.
The cohort used in this study was obtained from the SEER 18 registries, which spanned from 1973 to 2011 and covered 18 cancer registry sites around the United States. From this registry, all patients with a cancer in the head and neck region were included. Patients were classified according to cancer of 7 anatomical sites based on the “primary site-labeled” class, which includes the larynx (glottis, supraglottis, subglottis, laryngeal cartilage, larynx), hypopharynx (pyriform sinus, posterior cricoid region, aryepiglottic fold, hypopharynx), nasopharynx (nasopharynx and walls), oral cavity and oropharynx (external lip, mucosa of lip, commissure of lip, lip, tongue, lingual tonsil, gum, floor of mouth, hard palate, soft palate, palate, uvula, cheek mucosa, vestibule of mouth, retromolar area, tonsillar fossa, vallecula, epiglottis, pharynx, oropharynx), salivary glands (parotid gland, submandibular gland, sublingual gland), nasal cavity and sinuses (accessory sinus, sphenoid sinus, ethmoid sinus, frontal sinus, maxillary sinus), and thyroid gland.
Using the SEER program, patient data were obtained for sex, age, race, marital status, year of diagnosis, primary site of cancer, cause of death, survival time, cancer staging, course of treatment (radiation only, surgery only, both, or neither), and status at follow-up. Patients were considered to have committed suicide only if the cause of death on record was entered as “suicide and self-inflicted injury.” Patients’ marital status was classified as married, unmarried (which included single, widowed, or divorced), and unknown. Based on the TNM staging derived from the AJCC Cancer Staging Manual, 6th and 7th editions, the stage of the cancer at presentation was classified as localized (N0M0), regional (N+), distant (M1), or unknown (blank). Patients who survived less than 1 month after diagnosis were encoded in the SEER program as having a survival time of 0; these patients were assigned a survival time of 1 half-month in accordance with standard epidemiological calculations. Data analyses were performed in 2014.
Tables were created to compare survival time of patients with cancer based on different characteristics (eg, age, sex, race) using Microsoft Excel (Microsoft Corp). Suicide rates were then calculated per 100 000 person-years by dividing the number of suicides in each category by the total survival time (person-years) accumulated by the patients in the category. In the SEER database, the suicide rate of patients with cancer of a certain category was then compared with the US population suicide rate in that category, as collected by the National Center for Health Statistics, accessed through the SEER program. This was then used to obtain the standardized mortality ratio (SMR). For categories such as stage of presentation, year of diagnosis, cancer site, time since diagnosis, and radiation therapy and/or surgical therapy, the suicide rate in the US general population was used for comparison.
A total of 857 suicides were identified among 350 413 persons with head and neck cancer observed for 2 263 376 person-years, giving an age-, sex-, and race-adjusted suicide rate of 37.9 per 100 000 person-years. The corresponding suicide rate in the general US population was 11.8 per 100 000 person-years. This produced an SMR of 3.21 (95% CI, 2.18-4.23). For all patients with head and neck cancer in the SEER registries, regardless of cause of death, the range of survival time was 0 to 38.92 years, and the mean survival time was 5.61 years.
For the population as a whole, suicide rates trended downward over the 40 years covered in the SEER data. Suicide rates were statistically significantly higher in male patients and those with later stage disease. White race and unmarried status were also associated with high rates of suicide, although these were not statistically significant (Table 1). The Figure shows suicide rates by age at diagnosis and anatomic sites; for all patients, those diagnosed at ages 60 to 79 years had the highest rate of suicide. In addition, patients who received only radiation had approximately double the suicide rate of those who received only surgery.
Patients with tumors of each head and neck cancer site, except for the thyroid gland, had higher suicide rates than the general US population. Rates were highest in patients with cancers of the hypopharynx (164.2 per 100 000 person-years; SMR, 13.91; 95% CI, 11.78-16.03), larynx (64.7 per 100 000 person-years; SMR, 5.48; 95% CI, 4.14-6.81), and oral cavity and oropharynx (61.8 per 100 000 person-years; SMR, 5.23; 95% CI, 3.93-6.54).
Hypopharyngeal cancers were associated with the highest suicide rates in both men and women. In men, patients with nasopharyngeal cancers (87.3 per 100 000 person-years; SMR, 4.62; 95% CI, 3.65-5.59) had the second-highest rates, while for women the second-highest rates were seen among those with oral cavity and oropharyngeal cancers (18.4 per 100 000 person-years; SMR, 3.49; 95% CI, 1.90-5.09) (Table 2).
The greatest increase in suicide rates among all patients with head and neck cancer was seen in the first 5 years after diagnosis, with a subsequent decline over time. In patients with tumors of all sites except the thyroid gland and the nasal cavity and sinuses, suicide rates remained higher than that of the US general population for up to 10 years after diagnosis. Relative suicide risk remained high for longest with those with nasopharyngeal cancer, with an SMR of 3.26 (95% CI, 2.23-4.29) at more than 15 to 30 years after diagnosis. Hypopharyngeal cancer was associated with the highest initial suicide rate but was not significantly different from the general US population suicide rate after 10 years (SMR, 32.28; 95% CI, 29.04-35.52) (Table 3).
Radiation therapy without surgery was associated with a suicide rate of 60.4 per 100 000 person-years (SMR, 5.12; 95% CI, 3.83-6.41), while patients treated with surgery alone had a suicide rate of 30.4 per 100 000 person-years (SMR, 2.57; 95% CI, 1.66-3.49). Treatment with combined radiation and surgery had an SMR of 2.77 (95% CI, 1.82-3.72), and treatment with neither had an SMR of 4.64 (95% CI, 3.42-5.87) (Table 4).
In our study, hypopharyngeal, laryngeal, and oral cavity and/or oropharyngeal cancers were associated with the highest rates of suicide. We found a nearly 12-fold higher incidence of suicide in patients with hypopharyngeal cancer and a 5-fold higher incidence in those with laryngeal cancer. This may be linked to these anatomic sites’ intimate relationship with the ability to speak and/or swallow. Loss of these functions can dramatically lower patients’ QOL. It is possible that the increased rates of tracheostomy dependence and dysphagia and/or gastrostomy tube dependence in these patients are exacerbating factors in the increased rate of suicide observed. As Nguyen et al6 demonstrated, severe dysphagia (including cases in which patients are gastrostomy-tube dependent) was most significantly associated with lower QOL scores. Even in patients who are able to swallow, dietary modification and prolonged eating times can lead to anger and low self-esteem.7,8
An inability to speak is also significantly associated with depression and a lower QOL.6,9 This difficulty in communication may lead to social isolation and a lack of adherence to rehabilitation regimens.10 Tracheostomy dependence, which is particularly evident in patients with cancer of the hypopharynx and larynx, can create additional difficulties in speech. The neck disfigurement, noise in breathing, and mucus production resulting from a tracheostomy may lead to further social isolation and has been associated with increased rates of depression. Even patients who have been decannulated have incomplete psychosocial recovery.11
Although radiation is an integral part of treating many head and neck cancers, it can be associated with significant morbidity that is associated with lower QOL. Machtay et al12 showed that many patients were still gastrostomy tube–dependent and tracheostomy-dependent 1 or 2 years after combination chemotherapy and radiation therapy. Since laryngeal preservation therapy has become established, more patients are being treated with radiation; as a result, head and neck surgeons often have to perform salvage laryngectomies to prevent aspiration, aid in swallowing, and cure residual disease.13 IMRT had been widely commercially available in many centers by 2003, and by 2005 more than 75% of radiation oncologists in the United States were using IMRT. Compared with standard radiation therapy, IMRT has been associated with improved QOL and increased cause-specific survival.14,15 However, our data set shows the same incidence of suicide in patients well after 2005, many who presumably had received IMRT. There is likely a selection bias between those treated with radiation alone compared with those treated with surgery or with both surgery and radiation therapy. Patients with unresectable disease or significant comorbidities may undergo radiation therapy instead of surgery.
Most suicides occurred within the first 5 years of diagnosis. Following the first 5 years after diagnosis, there is a statistically significant decrease in the rate of suicide for every site (Table 3). This may be due to the acclimation to the anatomical and physiologic alterations following therapy as well as a lack of active treatment regimens.
Male sex is associated with a higher risk of suicide. In the general population, female sex is associated with a higher incidence of suicidal behavior, but male sex is associated with a higher incidence of completed suicide. This difference is attributed to more violent means of suicide attempts by men.16 It is possible that the incidence of female suicidal behavior in patients with head and neck cancer is underrepresented in the SEER data because failed suicide attempts are not recorded.
Age is also a significant risk factor in suicide in patients with head and neck cancer. However, the increased risk in the older population may be influenced by more advanced disease or more significant medical comorbidities.
Psychological distress, and depression especially, is frequently observed in patients with cancer.17- 19 Routine screening may not be needed in every patient, but we have identified a certain subset of patients often seen by otolaryngologists as being at increased risk (those who are older, male, with cancers of the hypopharynx, or with history of radiation therapy). Therefore, screening for depression and suicidal ideation should be considered in this high-risk group for primary prevention of suicide. The Distress Assessment and Response Tool (DART), an electronic questionnaire, identified suicidal ideation in almost 6% of patients with cancer who responded; of these, more than 10% reported suicidal intention as well.20 Other screening methods also report similar rates of identification, demonstrating the consistent effectiveness of these screening questionnaires.21
Many otolaryngologists may feel uncomfortable broaching the subject of depression with their patients. A commonly mistaken belief is that by asking about suicide, physicians may inadvertently cause psychological distress and motivate suicidal ideation. However, screening has not been found to have iatrogenic effects on suicide.22,23 Many surgeons may also feel inadequately trained to screen for suicidality. Referral to a mental health professional may be a reflex response for many physicians, especially surgeons. However, patient noncompliance with these referrals is a well-documented problem, and they may often be inadequate in preventing suicides.24
Patients expressing feelings of hopelessness, helplessness, social isolation, guilt, or other signs of depression should be asked to elaborate; identification of a suicide plan should raise concern for imminent suicidal attempts.25 When the physician’s clinical judgment determines that the patient poses a risk to his or her own life, confidentiality can and should be breached for referral to a mental health emergency department.
Despite the efficacy of antidepressants in the general population, studies have failed to find any benefit over placebo in patients with cancer with depression.26 These patients should be treated by a multidisciplinary approach with mental health professionals, primary care physicians, cancer nurses, and otolaryngologists. This is especially important when suicidal ideation is present and interventions such as cognitive behavioral therapy and multidisciplinary collaboration can be lifesaving.27,28
The findings from this study should be interpreted with the knowledge of several limitations associated with the SEER database. First, an inherent problem with SEER when evaluating for suicide is the possible misclassification of the cause of death. Second, comorbidities could not be ascertained from the SEER database. Substance abuse, including alcohol dependence and tobacco use, and psychiatric illness may also be linked to an increase in suicide rates in patients with head and neck cancer. It has been well established that smoking and drinking are linked to head and neck cancer, especially that of the larynx and hypopharynx, which may explain the increased suicide rate in this population as opposed to rates in patients with thyroid or salivary gland cancers. Finally, radiation therapy is often administered in conjunction with chemotherapy for many head and neck cancers. The SEER database does not report the use of chemotherapy, so this may be a confounder within the data set that cannot be addressed.
Suicide rates among patients with head and neck cancer are significantly higher than that of the general population. In particular, patients with hypopharyngeal and laryngeal cancer are at highest risk. While there is a considerable body of research that examines survival outcomes for patients with head and neck cancer, additional research and effort should also be devoted to the psychological toll that the cancer, treatments, and resulting morbidity have on patients.
Corresponding Author: Richard Chan Woo Park, MD, Department of Otolaryngology–Head and Neck Surgery, Rutgers New Jersey Medical School, 90 Bergen St, Ste 8100, Newark, NJ 07103 (email@example.com).
Published Online: November 12, 2015. doi:10.1001/jamaoto.2015.2480.
Author Contributions: Mr Kam and Dr Park had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Salib, Gorgy, Carniol, Eloy, Park.
Acquisition, analysis, or interpretation of data: Kam, Salib, Gorgy, Patel, Carniol, Baredes, Park.
Drafting of the manuscript: Kam, Salib, Gorgy, Patel, Carniol, Park.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Kam, Salib, Gorgy, Patel, Carniol, Park.
Administrative, technical, or material support: Carniol, Baredes, Park.
Study supervision: Carniol, Eloy, Baredes, Park.
Conflict of Interest Disclosures: None reported.
Previous Presentation: This study was presented at the Annual Meeting of the American Head & Neck Society; April 23, 2015; Boston, Massachusetts.