There are 10.6 suicides annually per 100,000 people in the United States, and suicide deaths are a significant health burden that is magnified when suicidal ideation and suicide attempts are also considered (1). A diagnosis of any medical illness increases the likelihood for suicide (2).
Furthermore, approximately 70% of all suicides in patients >60 years of age are attributed to physical illness, with higher rates in patients with cancer (2, 3). Secondary to these statistics, the National Comprehensive Cancer Network (NCCN) has developed protocols for screening and identifying levels of emotional distress in cancer patients in order to diagnose and treat psychiatric illnesses attributed to a cancer diagnosis (4).
Our study in Cancer (5) was the first to specifically look at suicide rates in patients with genitourinary malignancies compared to the general US population, subsequently identifying factors associated with suicide in this subset of patients. The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients diagnosed with prostate, bladder, kidney, testis, and penile cancer. Suicide incidence was compared to data from the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control, and standardized mortality ratios (SMRs) for each anatomic group were calculated. In this study, there was 2268 suicide events identified among 1,239,522 individuals with genitourinary cancer that were observed for 7,307,377 person years. The SMRs for patients with cancer were 1.37 for prostate cancer (95% CI, 0.99-1.86), 2.71 for bladder cancer (95% CI, 2.02-3.62), 1.86 for kidney cancer (95% CI, 1.32-2.62), 1.23 for testis cancer (95% CI, 0.88-1.73), and 0.95 for penile cancer (95% CI, 0.65-1.35).
In patients with genitourinary malignancies, increasing age, male gender, unmarried status, and distant disease were associated with suicide on multivariable analysis (5). These risk factors for suicide are not unlike those in the general US population; a diagnosis of genitourinary cancer intensifies this at risk population. Patients with other malignancies have the highest risk of suicide during the first three years after diagnosis (6), while patients with prostate cancer have significantly increased incidence of suicide over time. The highest incidence was observed ≥ 15 years after diagnosis (SMR 1.84 95%CI 1.39-2.41) (5). This may be secondary to late onset of metastases/symptoms, long-term urinary incontinence and erectile dysfunction, as well as financial hardship. Bladder cancer patients have a higher SMR for those who received surgical intervention compared with those who did not (cystectomy - SMR 3.54, 95%CI, 2.70-4.54 vs no cystectomy - SMR 2.66, 95%CI 1.95-3.54) (5). In addition to the anxiety of a cancer diagnosis, radical cystectomy is often associated with chemotherapy prior to surgery, prolonged recovery, and urinary diversion that significantly alters their body morphology and habits of daily living.
By quantifying suicide rates in patients with genitourinary malignancies and identifying factors associated with suicide, screening performed by clinicians and other health care providers for depression and suicidal ideation should be improved. Effective post-diagnosis and post-operative support (ie wound and ostomy nursing), in addition to early referral to mental health care providers for ‘at risk’ individuals should be implemented.
1. Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: a systematic review. JAMA 2005;294:2064-74.
2. Schneider RK. The Suicidal Patient. In: McKean SC, Ross JJ, Dressler DD, Brotman DJ, Ginsberg JS, editors. Principles and Practice of Hospital Medicine. New York: McGraw-Hill, 2002. p. 1915-20.
3. Misono S, Weiss NS, Fann JR, Redman M, Yueh B. Incidence of suicide in persons with cancer. J Clin Oncol 2008;26:4731-8.
4. National Comprehensive Cancer Network. Distress management. Clinical practice guidelines. J Natl Compr Canc Netw 2003;1:344-74.
5. Klaassen Z, Jen RP, DiBianco JM, et al. Factors associated with suicide in patients with genitourinary malignancies. Cancer 2005;121:1864-72.
6. Hultcrantz M, Svensson T, Derolf AR, et al. Incidence and risk factors for suicide and attempted suicide following a diagnosis of hematological malignancy. Cancer Med 2015; 4:147-54.
Zachary Klaassen, MD
Department of Surgery, Section of Urology
Medical College of Georgia – Georgia Regents University