Suicide Risk Associated with a Prostate Cancer Diagnosis
G.J. Nason, C. O’Connell, D.J Galvin
Department of Urology, Mater Misericordiae University Hospital
Suicide rates are consistently higher for patients diagnosed with cancer, even for those with low risk disease1. Patients with prostate cancer are at substantially higher risk than other solid organ malignancies2. It has been suggested that physicians should assess men diagnosed with prostate cancer for psychological illness such as anxiety or depression3.
Three of our patients have committed suicide in the past four years at various time points in their prostate cancer pathway. One man died two years post radical prostatectomy (RP)- he had a successful oncological outcome and made a full functional recovery. One man died ten weeks post RP- he had a successful oncological outcome and was meeting his early functional targets. One man died four weeks after diagnosis while deciding on a treatment plan. Only the last patient had a history of a mild depressive disorder with no prior suicide attempts.
Currently, men attending the Rapid Access Prostate Clinics do not undergo any formal mental health screening. Patients are brought through the suspected cancer pathway with the clinical team and clinical nurse specialist but no mental health screening tool is utilised as part of their assessment. Follow up appointments following RP traditionally focus on the trifecta of outcomes- oncological control, urinary symptoms and erectile (dys)function. Mental health indices and outcomes are not a performance indicator assessed as part of the NCCP for prostate cancer patients and as a result may not even register with their primary physician.
The reasoning behind prostate cancer patients being at higher risk than other cancer patients is multifactorial. Firstly- prostate cancer is usually diagnosed in asymptomatic men in their 50-60’s. The initial referral is often based upon an opportunistic PSA test by their GP. Men usually have no preceding symptoms to forearm them of a cancer diagnosis. Although it is recommended that prior to any PSA test, the patient and physician should have an informed conversation regarding prostate cancer. Despite this, the cancer diagnosis comes as a complete surprise to many men. Men with intermediate or high risk disease are then faced with a decision regarding treatment options (primarily surgery or radiotherapy) which both potentially have life changing consequences- namely urinary incontinence and erectile dysfunction3. Furthermore given this is a male disease- it is well accepted male patients are less likely to talk about their concerns. There is also less media awareness campaigns in comparison to other cancers such as breast or lung cancer. Finally, if adjuvant hormonal treatment is given for high risk disease, this can lower testosterone levels- however this was not the case with our three patients.
The spectrum of prostate cancer is another aspect which can confuse patients with prostate cancer which adds to their anxiety levels. Men present mainly incidentally however they can have low risk disease which predominantly requires surveillance while at the opposite end a proportion of men still present with widespread metastatic disease. A recent qualitative study assessed the ‘worst thing’ associated with a new cancer diagnosis4– the worst aspects reported by patients were receiving the initial diagnosis, plus the unknown outcome of that diagnosis, because of the possibility of death, loss of quality of life and/or partner, and the shock of the diagnosis. The most common coping strategy of men was to “just deal with it”. The identification of these specific worst aspects of the prostate cancer experience provides a set of potential treatment and prevention “targets” for psychosocial care in prostate cancer patients. Most of these factors are transferrable to most cancers. An analysis of the SEER healthcare database in the US demonstrated that improved healthcare experiences are noted with increased access to supportive care services5.
It may not be feasible either from a resource or an economic perspective to have all patients diagnosed with a new cancer assessed by an oncologic psychologist however a screening tool could be adopted in the cancer pathway. Physicians (hospital based and GPs) as well nursing staff need to be more aware of the adverse psychological effects of a cancer diagnosis6. At risk patients may include those with a prior history of mental health issues, those with substance abuse issues, those with poor social or family support networks or those who clearly struggle with the diagnosis. Not all patients will need to or have a desire to engage with additional support however all patients should be made aware of the facilities available at present. Consideration needs to be given to mental health screening of patients undergoing suspected cancer investigations.
Prehabilitation services are developing to optimise patients in advance of cancer treatments with respect to diet, exercise and patient expectations. Prehabilitation clinics prior to RP have shown to improve physical and psychological wellbeing in patients up to 26 weeks. These clinics give patients a focus and a support group prior to their surgery which helps patients meet other patients at various stages in the cancer pathway7. Survivorship clinics are also being developed to manage patients following treatment. There are support centres available that will see any cancer patient or family member (free of charge) however many patients are not aware of such facilities.
The psychological well-being of a patient could easily be integrated into prehabilitation and survivorship programs. At risk patients could be identified earlier and linked in with the appropriate support services to try to prevent further suicides in cancer patients. These services could be offer across all oncologic specialities and utilised as needs be.
Conflicts of Interest Statement
The authors have no conflicts of interest to report.
Mr. Gregory Nason, FRCS Urol, FEBU
Specialist Registrar in Urology,
Department of Urology,
Mater Misericordiae University Hospital,
Email: [email protected]
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