Head and Neck Cancer: Palliative Care Can Mitigate Risk of Suicide

U.S. veterans with head and neck cancer (HNC) have a high incidence of suicidal self-directed violence (SSDV), with subsequent death from those injuries, according to a retrospective cohort study looking at Veterans Health Administration data.

The study underscores the importance of identifying pre- and post-cancer risk factors for SSDV in this patient population, Shannon M. Nugent, PhD, from the Portland Health Care System, Portland, and colleagues noted in their study published in JAMA Otolaryngology-Head & Neck Surgery. The researchers also found that if HNC patients get palliative care within 90 days of their cancer diagnosis, the risk of SSDV decreased.

Suicide, in and of itself, ranks as the 10th leading cause of death for adults in the United States. A head and neck cancer diagnosis bolsters this statistic.

“Results from the Surveillance, Epidemiology, and End Results database found that survivors of head and neck cancer (HNC) are more than twice as likely to die by suicide compared with survivors of other cancer types (63.4 versus 23.6 suicides per 100,000 person-years) and 3 times as likely compared with the general population,” Nugent and colleagues wrote.

Thus, despite gains in treatment and survival for HNC, these patients have experienced a 27% increase in suicide rates in recent years, with those at the highest risk within 5 years of their diagnosis.

“The present cohort had an SSDV incidence of 203.9 deaths by suicide and 287.8 SSDV events per 100,000 person-years,” Nugent and colleagues wrote. “This is about 4 times the incidence of suicide compared with veterans with any diagnosed substance use or mental health disorders and 3 times higher than nonveteran HNC survivors.”

They also found that pre-diagnosis factors such as chronic pain, mood disorders, or self-directed violence events were independently associated with increased risk of SSDV once the diagnosis was made; substance use disorder and mental health treatment also increased risk.

Nugent and colleagues culled data from the VA’s Corporate Data Warehouse (CDW) and, from Jan. 1, 2021 to Jan. 1, 2018, looked at 24,368 patients diagnosed with HNC. There were 4,529 excluded due to an incomplete cancer diagnosis or treatment. After assessing 19,368, there were 12,026 patients excluded because of Stage IVC diagnosis, a second primary cancer, a recurrence of HNC, and salivary or thyroid cancer, leaving 7,803 patients in the cohort.

The objective of their study was to see if there was “an association between precancer mental health and pain and postcancer receipt of mental health, substance use disorder, or palliative care services with risk of suicidal self-diected violence,” Nugent and colleagues explained.

The main outcomes were an SSDV event or death by suicide post HNC diagnosis. Exposures included “the presence of precancer chronic pain and sustance use disorder (SUD) diagnoses, and postcancer SUD, mental health, or palliative care treatment.”

Most of the patients in the cohort were male (n=7,685); were non-Hispanic White (n=6,179), and their median age was 65 (SD10.7 years).

Cancer stage, treatment and histology of the survivors of HNC included in the cohort was:

• 2016 (25.8%) stage I.
• 941 (12.1%) stage II.
• 1189 (15.2%) stage III.
• 3657 (46.9%) stage IVA or IVB.
• Most underwent radiation (n=5,166; 66.2%), followed by chemotherapy (n=3,284; 42.1%) and surgery (n=2,906; 37.2%), and the treatments were not mutually exclusive.
• Squamous cell carcinoma was most common in 96.1% (n=7,500).
• Primary tumor sites were mostly pharyngeal (n=3,439; 44.0%) and laryngeal (n=2,365; 30.3%).

Notably, post diagnosis, more than half of the cohort, 64.6%, have a mental health or SUD diagnosis.

“Mood disorders, including major depressive disorder, bipolar disorder, and dysthymia, were the most common [mental health] diagnoses before (n=1,560; 20.0%) and after (n=2,046; 26.2%) HNC diagnosis,” the study authors wrote. “Nicotine use disorder was the most commonly diagnosed SUD before (n=2,355; 23.7%) and after (n=2,445; 24.6%)HNC diagnosis.”

For those with any documented mental health or SUD, these increased from before cancer diagnosis to after: (2,198 [28.2%] vs 3,401 [43.6%]). And, not surprisingly, 35.2% reported chronic pain 2 years following their cancer diagnosis versus 19.6% precancer diagnosis.

Following their cancer diagnosis, 72 patients had an SSDV and 51 died by suicide.

The cohort was followed for a mean of 3.2 (SD 2.1) years, totalling 25,015 person years, and in that time the study authors found 203.9 deaths and 287.8 SSDV events per 100,000 person-years.

The most common means of SSDV were:

• Self-poisoning by 28 individuals, with 14 of them dying.
• Firearm discharge by 33, all of whom died.

Of note: “Almost half (n=32; 44.4%) of SSDV events were more than 2 years after the diagnosis, though 18 (25.0%) individuals had an event within 6months of their cancer diagnosis. For 67 (93.1%) individuals with a postcancer SSDV event, it was the first documented SSDV event in their medical history,” Nugent and colleagues wrote.

In the cohort, 2,074 had a palliative care consult, 3,401 had a mental health treatment encounter, and 435 had a SUD treatment encounter.

“Those with documented SUD treatment prior to their SSDV event (n=24) had shorter time to SUD treatment (mean [SD], 92 [151] days) compared with those without documented SSDV (n=411; mean [SD], 137 [167] days),” the researchers wrote. “Those who received palliative care and had documented SSDV (n=29) had a longer time to first palliative care treatment (mean [SD], 276 [242] days) compared with those who did not have an SSDV event (n=2045; mean [SD], 149 [172] days).”

Nugent and colleagues pointed out the high symptom burden that survivors of HNC have, including “disfigurement and pain during speaking, swallowing, and eating, secondary to their disease and cancer treatment, all contributing to distress and poor quality of life. This study’s findings are consistent with the high pain and psychological symptom burden following HNC treatment found in other studies,” they wrote.

The study, as Sean T. Massa, MD, Department of Otolaryngology–Head and Neck Surgery, Saint Louis University Hospital, Missouri, and colleagues point out in an accompanying editorial, is not without its limitations, namely the retrospective, observational design, which may limit its generalizability outside of the VA health system.

“Several oncologic variables are not included in this study’s models, including cancer site, stage, and treatment, which have previously been associated with suicide and could have an effect on results,” the editorialists wrote. They also noted that the study makes a presumption: “that identification of suicidal individuals could be used to intervene before a suicidal act; unfortunately, this approval within the context of oncologic care is complex, and established interventions are lacking.”

Massa and colleagues did commend the study authors for including modifiable risk factors in their analysis, as well as showing “a protective association between a palliative care encounter and risk of a suicidal act.”

Still, the editorialists called the study “important” and noted: “this study moves the field forward in several important ways and emphasizes the importance of multidisciplinary care.”

1. U.S. veterans with head and neck cancer (HNC) have a high incidence of suicidal self-directed violence (SSDV), with subsequent death from those injuries, according to a retrospective cohort study.

2. The study underscores the importance of identifying pre- and post-cancer risk factors for SSDV in this patient population and found that if HNC patients get palliative care within 90 days of their cancer diagnosis, the risk of SSDV was decreased.

Candace Hoffmann, Managing Editor, BreakingMED™

Cat ID: 120

Topic ID: 78,120,730,120,935,130,192,925