January 13, 2012

Veterans groups and new organizations are rightfully sounding the alarm about the “epidemic” suicide rate among young men and women who have served in Iraq or Afghanistan. Reaching 44.99 per 100,000 in 2005, that rate far surpasses the 34.5 per 100,000 recorded for veterans returning from Vietnam, and is catastrophically high compared to the national average of 11.1 per 100,000.

Hotlines have been established; training has been implemented; and resources have been marshaled to stem the tragic premature loss of life by enhancing the identification and treatment of depression in active duty military and veteran populations.

Consider, now, the suicide rate of pancreatic cancer patients in the SEER (Surveillance, Epidemiology and End Results) database of the National Cancer Institute: 135.5 per 100,000, reported by Turaga and associates in the journal Cancer.

In their careful study and echoed in a beautifully written accompanying editorial by Dr. Donna B. Greenburg of Massachusetts General Hospital, the researchers note that the pancreatic cancer patients most at risk for suicide mirror those most at risk in the general population: unmarried men, in this case those between 65-75 years old.

Dr. Greenburg points out the poignant irony inherent in the statistics: that although suicide in pancreatic cancer is startlingly high from an epidemiologic point of view, it is so rare in practice that “most oncologists, even those who are caring for pancreatic cancer alone, could believe that no patients kill themselves when faced with this diagnosis.”

By the numbers, 30 of 36,221 pancreatic adenocarcinoma patients officially died at their own hands between 1995 and 2005. All but 2 were men. Most were unmarried. Just 4 were younger than 60.

A closer look at the stories behind the numbers documented by Dr. Kiran Turaga and colleagues from the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Fla., proves intriguing.

Ironically, among men, suicide was associated with surgery, even though such patients would normally be presumed to have a more favorable prognosis than for those whose cases were considered inoperable. For patients who underwent surgery and then took their lives, median survival was 2 months, compared with 10 months in other pancreatic cancer patients who underwent surgery. In 5 patients who committed suicide, surgery was offered, but declined.

It raises the question, what happened during the 8 months of life experienced by pancreatic cancer patients who had surgery and did not take their lives? Were there days they wouldn’t have traded? Moments of clarity, of purpose, of deep connection with those they loved?

And what, asks Greenburg, might distinguish those who chose, impulsively or agonizingly, to end their lives within an average 60 days of surgery?

“They took the option for cure,” she wrote. “They may have been more action oriented, more at risk of delirium, more worried about recurrence, more disappointed if the disease was not cured, more intoxicated; or they may have had an extensive lifetime history of affective disorder.”

She compares suicide to sepsis, “the worst outcome of a serious, treatable condition,” in this case major depressive disorder, which “darkens perception even for an individual who has no medical illness.”

“When depressed,” she writes, “a man feels small, worthless, hopeless. Hope is a function of self-esteem; with cancer, he may feel that his potential for being someone who matters has been exhausted.”

As anyone who has treated cancer patients can attest, that perception may be quite distorted indeed. Transformations occur in life’s waning days. Truths are spoken. Relationships are mended. Meaning-making weaves its way into a legacy’s tapestry.

And, despite the time-limited prognosis for most pancreatic cancer patients, it seems to me that screening for major depressive disorder (as opposed to existential angst) is not only warranted, but strikes at the heart of what it means to treat patients as if they truly matter, no matter how long they have to live.

Betsy Bates Freed is a clinical psychologist in Santa Barbara, Calif., and a medical journalist.

 

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