Some Childhood Cancer Survivors Face Suicide Risk As Adults

BOSTON, Aug. 18 -- For a few survivors of childhood cancer, the pain, depression, and other aspects of diagnosis and treatment can turn thoughts in adulthood to suicide, a study here suggested.

Of 226 adult survivors of childhood cancer, 29 (13%), reported suicidal symptoms nearly two decades after diagnosis and successful treatment , said Christopher J. Recklitis, Ph.D., M.P.H., of the Dana-Farber Cancer Institute here, and colleagues reported in the Aug. 20 issue of the Journal of Clinical Oncology.

"Despite the substantial literature describing suicidality in patients undergoing cancer therapy, few studies have examined suicidal symptoms in the years after treatment," Dr. Recklitis and colleagues wrote.

Their study involved 100 men and 126 women ages 18 to 64 (average age: 28). Their average age at cancer diagnosis was 10, and the average time since diagnosis was 18 years. Childhood cancers included lymphomas (33%), leukemias (32%), Wilm's tumor (7.5%), and other solid tumors (13%).

During a routine follow-up visit to a cancer survivor clinic, the participants underwent an array of psychological and quality-of-life assessments, including the Beck Depression Inventory and the Beck Scale for Suicidal Ideation.

Of the 29 participants reporting suicidal ideation, nine (nearly 4%) had attempted suicide. In addition, one participant not reporting suicidal ideation had also attempted suicide. Although the study did not use a control group for comparison, "survivors in the study reported higher rates of suicidal symptoms than expected based on normative population reports," the investigators said.

Further analysis identified several risk factors associated with suicidal symptoms:

• Younger age at diagnosis (P<.001)
• Longer time since diagnosis (P<=.003)
• Cranial radiation treatment (P<.001)
• Depression (P<.001)
• Feelings of hopelessness (P<.001)
• Pain (P=.01)

There was a trend toward poorer physical functioning also being a risk factor, but it did not reach statistical significance (P=.075).

"A relationship between pain and suicidality has been reported previously in cancer patients, but these results extend those findings by indicating that the relationship persists into the survivorship period," the investigators said.

Pain and poor physical functioning can result from radiation or surgical damage to bone and muscle tissue, impairing one's ability to walk or carry out the tasks of everyday life, Dr. Recklitis said in an interview.

Such chronic pain and difficulty can contribute to feelings of depression and hopelessness, he added.

However, only 11 of the 29 participants with suicidal ideation scored high enough on the Beck Depression Inventory to indicate clinically significant depression. "This has important implications for developing programs to identify those cancer survivors at risk for suicidal symptoms because it implies that screening for depression alone may not be adequate," the authors wrote.

Cranial radiation treatment, once widely used in leukemia treatment, may increase the likelihood of suicidal symptoms because it has been linked to neuropsychological problems and sometimes causes physical disfigurement, the authors said. They noted that concern about one's physical appearance was also identified as a risk factor for suicidal symptoms (P<.001).

Intense doses of cranial radiation could cause problems with learning and memory, which could lead to frustration and problems in school or at work, which in turn might raise the risk for depression, he said.

Younger children may be more vulnerable to the toxic effects of cranial radiation treatment, which may help explain why a younger age at diagnosis was a risk factor, the authors said.

On the other hand, children also tend to be diagnosed with leukemia at a younger age, compared with other cancers, Dr. Recklitis said. Even if leukemia patients did not undergo cranial radiation, their course of therapy was much longer and more intense than others, which may be linked to later physical and psychological problems, he said.

Now that many leukemia patients are treated without cranial radiation, future studies should be able to more accurately assess the impact of this type of therapy on suicide risk by comparing those who received it with those who didn't, the authors said.

Although cranial radiation may be a big factor behind the study results, it is certainly not the only one, Dr. Recklitis said. Chronic pain and limited physical functioning also contributed to suicide risk even in patients who had not undergone cranial radiation, he pointed out.

"Although the vast majority of survivors reported no suicidality, the significant minority of survivors with thoughts of ending their lives is a serious concern," the authors said.

"The association with physical health and pain is important because these represent potentially treatable conditions for which survivors may seek follow-up care," they added.

The study suggested that researchers studying cancer survivors should make certain they take into account both physical and emotional factors affecting health, the authors said.

"Similarly, in clinical care, providers from different disciplines can independently assess different domains of physical and psychological well-being, but only by integrating these perspectives can they develop an accurate understanding of the survivor's health and quality of life," they concluded.