Suicide Risk after a Cancer Diagnosis

Have you had dark thoughts after a cancer diagnosis?

For all the years of my career, the conventional wisdom has been that the suicide rate among cancer patients is no different than that of the general population. In my clinical experience, almost everyone thinks about suicide after learning of a cancer diagnosis, but most people consider it as a safety valve, a back door out of an impossible situation if that were ever necessary. Many years ago, I had a patient who was killed in a questionable automobile accident, leaving open the question as to whether it had been purposeful. A few years ago, a colleague’s patient went home and shot himself after learning from his doctor that there was no more available treatment that might be helpful. Two deaths from suicide, although terrible, is a small number over the course of 40 years and thousands of patients.

This is a very serious topic and one that is often taboo. Since I firmly believe that opening up any conversation, even tough ones, is the first step towards alleviating a problem or helping a situation, this is important to consider.

Oncology social workers, like those at the BIDMC Cancer Center's social work group, and other clinicians are taught how to assess for a suicide risk and how to talk about it. Although it initially feels very awkward, it quickly becomes clear that asking the questions is never shocking to the patient, and, often, having a chance to talk about thoughts and fears provides relief. This is different from the issue of physician-assisted suicide, although that is another topic that I often discuss. A few years ago, I worked with a woman who was very ill and seriously considering a one-way trip to somewhere in Europe where this act was legal. We talked about it for weeks, going over all the details, and, in the end, she chose not to go. Looking back, I know it was a very helpful way of maintaining a feeling of control over her situation to think about this trip. Feeling sick and alone and powerless is impossibly sad.

I am thinking about this because of two recent studies that change the conversation. One found that the risk of suicide was significantly higher for a year after a cancer diagnosis and that the overall risk was 2.5 times higher for cancer patients than for the general population. The second study, to my even greater surprise, found that cancer patients are about four times more likely to die from suicide than the general population. Both studies suggested that the risk varied among different cancer diagnoses, and was especially high for the most lethal cancers.

What do we make of this? Especially what do we make of the apparent change in numbers? Were the earlier studies wrong? Are these new studies wrong? Has something changed? Is suicide, in general, less taboo than in the past?

It is critical to differentiate between suicidal ideation and suicidal intent. Cancer patients are all, at some point, thinking about death, and talking about suicide is one way to approach the topic. It has always been my experience that it is helpful and relieving to be able to talk about the scariest subjects, and having a safe place to do so can be critical. It is virtually impossible to be diagnosed with cancer and go through cancer treatment without considering mortality.

In summary, all studies, both older and newer, suggest that the risk rises with the seriousness of the cancer, is greater in the early weeks following diagnosis, is exacerbated by pain and the side effects of the disease or treatment, and is inversely related to the patient’s support system. Someone with a past personal or family history of major depression and/or suicide attempts is at higher risk.

Why is this important? First, we need to acknowledge the stresses and worries that accompany cancer. It is helpful to honestly express one’s deepest fears and sadness and to have a safe person to listen and a safe place to talk. Thinking about suicide almost never translates to acting on the thought. Almost everyone with cancer, someone along the line, thinks something like: “If this gets to be more than I can bear, if the pain is intractable, and I am never getting better, I want to be able to end it.” This is trying to take some control. Believing that there is an escape route makes most of us better able to tolerate the situation. It is also important to write about this in the hopes of normalizing the thoughts that virtually all cancer patients sometimes have. Just thinking about suicide does not make it happen. Just considering the fact that suicides sometimes happen does not increase the likelihood. 

If you or someone whom you know is deeply depressed, feeling hopeless about ever feeling better, not looking forward to anything, thinking often of suicide or has a plan, speak up. Please. Help is always available. It does not matter with whom you start the conversation. Just start it.