For the significant minority of adult survivors of childhood cancer who consider suicide, suicidal thoughts and attempts are related to cancer treatments and to mental and physical health following treatment. That was the conclusion of a study published in the Journal of Clinical Oncology (2006;24:3852–3857).
“It is an important reminder that problems in physical functioning may very well be related to problems in emotional functioning,” said lead author Christopher J. Recklitis, PhD, MPH, Director of Research at the Perini Family Survivors' Center of Dana-Farber Cancer Institute, in an interview.
“So if you're treating a patient for pain or someone's frustrated with his education or other things, you need to think perhaps a little more quickly about what's the emotional cost to this and how to assess that.”
Of the 226 adult survivors of childhood cancer participating in the study, 29 (12.83%) reported suicidal thoughts or attempts.
This figure included 19 participants who indicated suicidal ideation alone, one who reported past suicide attempts without current ideation, and nine who reported both current suicidal thoughts and past attempts.
Most Suicidal Patients Not Depressed
While many studies have assessed suicidal symptoms in patients being treated for cancer, few have done so for the years following treatment, Dr. Recklitis and colleagues wrote.
In their study, the mean time that had elapsed since diagnosis was 18.30 years, and the mean age of the participants was 28.
The study was funded by a Survivorship Research Grant from the Lance Armstrong Foundation; and Lisa R. Diller, MD, Chief Medical Officer of Dana-Farber/Children's Hospital Cancer Care and Clinical Director of Pediatric Oncology at Dana-Farber Cancer Institute and Children's Hospital Boston, was the senior author.
Participants reporting suicidal ideation on the Beck Depression Inventory (BDI) or Symptom Checklist-90 Revised (SCL-90-R), or a past suicide attempt on the Beck Scale for Suicidal Ideation item, were classified as suicidal.
“Most studies, including ours, show that the majority of adult survivors of childhood cancer are doing fine,” Dr. Recklitis said.
“Having said that, it's still significant that there's a small minority that have this particularly worrying sympton of current thoughts of ending their lives, which seems to be significantly higher than what we would expect based on other studies in the community and the general population.”
Risk factors for suicidal ideation and attempts in the study participants included those previously reported in cancer patients and in the general population, such as depression and hopelessness. Younger age at diagnosis and cranial radiation were also linked to suicidal symptoms.
Even after controlling for cancer treatment and depression, current physical functioning, including pain, significantly increased the likelihood of reporting suicidal symptoms. Of the 29 participants who indicated they had considered or attempted suicide, only 11 had clinically significant depression.
“Clinical psychiatric depression may not be what's driving suicidal ideation in this group,” Dr. Recklitis said. “It may be more frustration and physical dysfunction and those kinds of problems of living.”
‘Incredible Strengths, Some Limitations’
This study suggests the need for more psychosocial services for this group, commented Jennifer S. Ford, PhD, Assistant Attending Psychologist at Memorial Sloan-Kettering Cancer Center, who was not involved with the study.
“This is just a very preliminary start, and I think it raises lots of questions. It says to me we need to have more funding so more research can get done and we can answer more questions and figure out what these individuals really need.”
Dr. Ford highlighted the sample size, the inclusion of suicidal ideation in addition to attempts, the use of validated measures, the reliance on self-reports instead of parent reports, and the representativeness of the sample in terms of age at diagnosis and current age as strengths of the study.
“There are some incredible strengths here,” she said. “There are some limitations. I think he [Dr. Recklitis] does a very nice job of acknowledging those, and I think taking those caveats and moving forward will hopefully be a next step for these investigators.”
For example, since the participants were a convenience sample, they were not necessarily representative of the survivorship population as a whole.
“The other limitation is reports of suicidal ideation can actually differ in different assessments, and they actually found that as well,” she added, referring to the multiple questionnaires used.
“I would say for future studies you'd want some sort of comparison group and potentially some sort of clinical interview to really assess suicidal ideation. I would probably also separate out ideation from attempts.”
The analysis was complicated by the relationships among the variables themselves, Dr. Recklitis mentioned.
For example, while both young age at diagnosis and cranial radiation were related to suicidal symptoms in the study, they also are strongly associated with a diagnosis of acute lymphoblastic leukemia, raising the possibility that they act as markers for diagnosis and do not have a direct effect on suicidality.
Multidisciplinary Care Needed
Further study may address these limitations and help parse out the effects of possible confounding factors. Dr. Recklitis is working with other researchers to analyze data on suicidal ideation from the Childhood Cancer Survivor Study (CCSS), which includes more than 14,000 survivors of childhood cancer.
“That will be very important because it will include a much larger group of patients,” he said. “It will be representative, so it won't be patients treated at one particular institution.”
“I think we'll be able to tease apart the issues of cranial radiation more from diagnosis, and most importantly, perhaps, we also have a control group of siblings.”
The link between suicidal symptoms and physical functioning seen in this study indicates that care must be integrated, Dr. Recklitis said.
“If physical health and mental health are so entwined in this important way, it certainly makes sense that I as a psychologist would be assessing depression and suicidal ideation and anxiety and health behaviors, and an oncologist or nurse practitioner would be looking at pain and physical function, but if we don't talk to each other, we're not going to see the whole picture.”