Nosayaba Osazuwa-Peters, PhD, BDS, MPH, CHES, on Understanding Suicidality Among Survivors of Head and Neck Cancers

Suicide is a complex issue among all cancer survivors, but is especially so among survivors of head and neck cancers.

Although these cancers only comprise about 4% of new cancer cases among Americans, new research has found that the rate of suicide is significantly higher in head and neck cancers compared with most other cancers.

This finding emerged from a study of 4,219,097 US cancer survivors, using 2000-2014 data from the Surveillance, Epidemiology, and End Results 18-registry database. Overall, 4493 suicides had occurred (incidence rate: 23.6 suicides per 100,000 person-years).

However, compared with survivors of other cancers, patients who had survived head and neck cancers were found to be nearly twice as likely to die from suicide. A total of 404 suicides had occurred among 151,167 survivors of head and neck cancers, with an incidence rate of 63.4 per 100,000 person-years.

Furthermore, suicide risk among survivors of head and neck cancers had increased by 27% during the period from 2010 to 2014 compared with the period from 2000 to 2004.

Consultant360 spoke with the study’s lead author, Nosayaba Osazuwa-Peters, PhD, BDS, MPH, CHES, assistant professor at the Saint Louis University School of Medicine and member of the Department of Otolaryngology-Head and Neck Surgery at the Saint Louis University Cancer Center.

He provided us with insight on suicide risks among survivors of head and neck cancers — the contributing factors, how clinicians can help lessen suicide risk among these patients, and areas still in need of further research.

Consultant360: What is quality of life typically like among survivors of head and neck cancers?

Dr Nosayaba Osazuwa-Peters: Quality of life has always been an issue among patients with head and neck cancers, partly due to the function and structures often involved in head and neck tumors, as well as the anatomic complexity of the region. Deciding the intent of treatment—cure, functionality, or aesthetics—is a unique issue that often arises in this patient population. Unfortunately, many head and neck cancer patients have to sacrifice functionality for cosmesis or aesthetics, which often results in quality of life problems.

Adverse effects on quality of life are almost unavoidable irrespective of treatment intent or modality in head and neck cancers. Studies have reported that there are virtually no head and neck cancer patients who experience no post-treatment complications or toxicities. Both surgical and adjuvant treatments are often associated with adverse quality of life issues. Surgical treatment is associated with the risk of facial disfigurement, pain, dysphagia, speech, and compromised ability to swallow. Radiation treatment tends to be associated with xerostomia, mucositis, dysgeusia, and, in the long-term, osteoradionecrosis.

Rates of depression among head and neck cancer patients can be as high as 50% or as low as 9%, depending on the measures used.

C360: Your study found that suicide risk is significantly higher among head and neck cancer survivors compared with the vast majority of other cancers. Why do you think this is the case?

Dr Osazuwa-Peters: Suicide is an extremely complex problem among survivors of head and neck cancers. There is no one factor that can be pinpointed as the main driver of suicide in this patient population, and as a result, it is very difficult to prevent. Cancer survivors as a whole face a myriad of quality of life issues, all of which may act independently or synergistically to drive suicidal ideation. However, survivors of head and neck cancers in particular suffer uniquely from aesthetic and functional compromises that could trigger suicidal thoughts or actions.

Head and neck cancers also significantly impact many important social and cultural aspects of daily life that we often take for granted, including the ability to enjoy food. In nearly all cultures, food is not just for nutrition and sustenance, but it is also an important sociocultural aspect of life. Celebrations, family life, and many other day-to-day social activities are built around food and sharing a meal. However, many survivors of head and neck cancers lose their ability to taste or smell food, and many never recover this ability even years after treatment has ended. One cancer survivor once told me, “Doc, every food I eat just tastes like cardboard.”

Survivors of head and neck cancers often lose their ability to socialize with others around them because of concerns about their characteristic facial profile and sensitivity about body image. While body image issues may be concerning in public, many survivors also struggle with their body image even with their spouses, resulting in a loss of self-confidence and low self-worth. This could impact sexual satisfaction among those with partners and could create other concerns within families.

Many patients face serious financial struggles. Head and neck cancers have previously been described as the most expensive cancer to treat. Approximately half of head and neck cancer survivors are unable to return to work and are functionally disabled post-treatment. Many head and neck cancer patients, especially men, struggle with becoming a burden to their spouses and families and may decide that they are better off dead.

Again, it is difficult to tell the exact mechanism that may be driving suicide rates among head and neck cancer survivors, but there is reason to believe that all of the factors described above may play a role. More studies are critically needed to understand this problem because, historically, there have never been more cancer survivors than there are today. However, there is more to survival than simply existing each day, which is why understanding suicide risk among survivors is crucial.

C360: What steps should clinicians take to ensure psychological wellbeing and help prevent suicides in this patient population?

Dr Osazuwa-Peters: It is important to raise awareness about suicide as a threat to cancer survivorship. It can be easy to blame physicians for not discussing psychosocial problems with their patients. It is indeed true that many physicians do not feel comfortable discussing this issue. However, the goal of cancer treatment is fundamentally to cure a patient, if at all possible. Thus, issues like depression or suicide that are non-surgical or within the primary treatment modality may not receive as much attention.

Conversely, recent conversations among clinicians have revealed that some patients may be reticent to discuss suicidality and other psychosocial struggles with their clinicians. It is therefore important for physicians to be aware that patients may not discuss this issue at all unless their physician initiates the conversation.

Patients’ relatives or other members of their close support network can also play a role. They may be able to help provide a patient’s treatment team with important feedback on mood changes or behaviors that could suggest the patient might be struggling mentally or emotionally.

C360: What would you say are the next steps in your research? What knowledge and educational gaps still exist when it comes to understanding the psychosocial wellbeing of head and neck cancer survivors?

Dr Osazuwa-Peters: There are still so many unknowns to the suicide epidemic that need to be understood. Suicide is the tenth leading cause of death in the United States overall and, depending on the age group, can be as high as the second leading cause of death. Cancer, on the other hand, is the second leading cause of death in the United States overall and has already overtaken cardiovascular disease as the number one cause of death in about 22 states.

There is an obvious need for greater funding toward research of the cancer-suicide interplay. But unfortunately, suicide research is one of the most underfunded areas of research in the United States.

My research team and I intend to continue to learn more from physicians, cancer survivors, and their families about suicidality among head and neck cancer survivors and modifiable risk factors. Going forward, we plan to delineate gender differences in suicide risks, track trends in suicide rates based on gender, and examine how much of a role depression plays in suicide.

I am particularly interested in the depression-suicide link. There seems to be a common belief that depression might equate suicide, but current evidence suggests the contrary.

—Christina Vogt

Reference:

Osazuwa-Peters N, Simpson MC, Zhao L, et al. Suicide risk among cancer survivors: Head and neck versus other cancers. Cancer. 2018;124(20):4072-4079. https://doi.org/10.1002/cncr.31675.