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Original Investigation
January 2019

Risk of Suicide After Cancer Diagnosis in England

Author Affiliations
  • 1National Cancer Registration and Analysis Service, Public Health England, Wellington House, London, United Kingdom
  • 2Bury St Edmunds GP Specialty Training Programme, West Suffolk Hospital, Bury St Edmunds, United Kingdom
  • 3Transforming Cancer Services Team for London, Skipton House, London, United Kingdom
  • 4Department of Surgery, West Suffolk National Health Service Foundation, Bury St Edmunds, Suffolk, United Kingdom
  • 5UCL Division of Psychiatry, University College London, London, United Kingdom
  • 6Camden and Islington National Health Service Foundation Trust, St Pancras Hospital, London, United Kingdom
  • 7St George’s University Hospitals National Health Service Foundation Trust, London, United Kingdom
JAMA Psychiatry. 2019;76(1):51-60. doi:10.1001/jamapsychiatry.2018.3181
Key Points

Question  What is the risk of suicide after cancer diagnosis in England, and which subgroups of patients are most at risk?

Findings  In this population-based study of 4 722 099 adult patients with cancer, a 20% increased risk of suicide compared with the general population was noted, corresponding to 0.19 excess deaths per 10 000 person-years. Patients with mesothelioma, pancreatic, esophageal, and lung cancer had the highest risk.

Meaning  The first 6 months after diagnosis of cancer has been shown to be a critical period, identifying the time during which cancer care pathways should pay particular attention to the psychological health needs of the patients; as suicide is hard to predict, all patients should receive improved psychological support.

Abstract

Importance  A diagnosis of cancer carries a substantial risk of psychological distress. There has not yet been a national population-based study in England of the risk of suicide after cancer diagnosis.

Objectives  To quantify suicide risk in patients with cancers in England and identify risk factors that may assist in needs-based psychological assessment.

Design, Setting, and Participants  Population-based study using data from the National Cancer Registration and Analysis Service in England linked to death certification data of 4 722 099 individuals (22 million person-years at risk). Patients (aged 18-99 years) with cancer diagnosed from January 1, 1995, to December 31, 2015, with follow-up until August 31, 2017, were included.

Exposures  Diagnosis of malignant tumors, excluding nonmelanoma skin cancer.

Main Outcomes and Measures  All deaths in patients that received a verdict of suicide or an open verdict at the inquest. Standardized mortality ratios (SMRs) and absolute excess risks (AERs) were calculated.

Results  Of the 4 722 099 patients with cancer, 50.3% were men and 49.7% were women. A total of 3 509 392 patients in the cohort (74.3%) were aged 60 years or older when the diagnosis was made. A total of 2491 patients (1719 men and 772 women) with cancer died by suicide, representing 0.08% of all deaths during the follow-up period. The overall SMR for suicide was 1.20 (95% CI, 1.16-1.25) and the AER per 10 000 person-years was 0.19 (95% CI, 0.15-0.23). The risk was highest among patients with mesothelioma, with a 4.51-fold risk corresponding to 4.20 extra deaths per 10 000 person-years. This risk was followed by pancreatic (3.89-fold), esophageal (2.65-fold), lung (2.57-fold), and stomach (2.20-fold) cancer. Suicide risk was highest in the first 6 months following cancer diagnosis (SMR, 2.74; 95% CI, 2.52-2.98).

Conclusions and Relevance  Despite low absolute numbers, the elevated risk of suicide in patients with certain cancers is a concern, representing potentially preventable deaths. The increased risk in the first 6 months after diagnosis may indicate an unmet need for psychological support. The findings of this study suggest a need for improved psychological support for all patients with cancer, and attention to modifiable risk factors, such as pain, particularly in specific cancer groups.

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