Suicide Risk in Men with Prostate-Specific Antigen–Detected Early Prostate Cancer: A Nationwide Population-Based Cohort Study from PCBaSe Sweden

doi:10.1016/j.eururo.2009.10.035

European Urology

Volume 57, Issue 3, March 2010, Pages 390-395

https://doi.org/10.1016/j.eururo.2009.10.035 Get rights and content

Abstract

Background

The risk of suicide is increased among cancer patients including men with prostate cancer (PCa). However, whether this increased risk applies to men diagnosed subsequent to prostate-specific antigen (PSA) testing is not known.

Objective

To assess the risk of suicide among men diagnosed with PCa subsequent to PSA testing.

Design, setting, and participants

The Prostate Cancer Base Sweden (PCBaSe Sweden) database, the Swedish Cause of Death Register, and the Swedish census database were used. The PCBaSe Sweden is a merged database that includes data from the Swedish National Prostate Cancer Register (NPCR) for cases diagnosed between January 1, 1997, and December 31, 2006. The number of suicides registered for cases in the PCBaSe cohort was compared with the expected number of suicides in an age-matched general male Swedish population.

Measurements

Standardised mortality ratios (SMRs) with 95% confidence intervals (CIs) were calculated for different categories of cases.

Results and limitations

There were 128 suicides among the 77 439 PCa cases in the NPCR compared with an expected number of 85 (SMR: 1.5; 95% CI, 1.3–1.8). The risk of suicide was not increased for the 22 405 men with PSA-detected T1c tumours (SMR: 1.0; 95% CI, 0.6–1.5), whereas the 22 929 men with locally advanced nonmetastatic tumours (SMR: 2.2; 95% CI, 1.6–2.9) and the 8350 men with distant metastases (SMR: 2.1; 95% CI, 1.2–3.6) had statistically significant increased SMRs for suicide. Potential effects of comorbid medical and psychiatric conditions could not be investigated.

Conclusions

No increased risk of committing suicide was observed among men with PCa diagnosed subsequent to PSA testing, whereas the risk was twice as high among men with locally advanced or metastatic disease, compared with an age-matched male population.

Introduction

The introduction of prostate-specific antigen (PSA) testing as a screening tool for early detection of prostate cancer (PCa) in the beginning of the 1990 s drastically increased the detection of PCa and widened the gap between incidence and mortality [1]. Although there is no official PSA screening program in Sweden, the proportion of men diagnosed with low-risk, early stage PCa due to testing of serum PSA has increased yearly. In 2005, >40% of all men diagnosed with PCa in Sweden were diagnosed with nonpalpable tumours on the basis of PSA testing as compared with <10% in 1996 [2]. Early detection of PCa by means of PSA testing increases the risk of overdiagnosis and results in no or a small survival benefit [3], [4].

Today, multiple lines of evidence indicate the risk of suicide is increased in cancer patients including men with PCa [5], [6], [7], [8]. It is unknown, however, whether this heightened risk exists for all stages of PCa including early nonpalpable PCa, detected by PSA testing.

Although depression is a major risk factor for suicide, other factors also play a role, such as family discord, lack of social support, and functional limitations, especially among the elderly [9]. We hypothesised that a diagnosis of a low-risk PCa detected subsequent to PSA testing may increase the patients’ risk of suicide due to psychological reactions associated with a cancer diagnosis [10], [11]. We also examined the risk of suicide in relation to tumour characteristics and time since diagnosis.

Section snippets

Study population

This study was performed within the Prostate Cancer Base Sweden (PCBaSe Sweden), a database in which a number of different registers are merged [12]. PCBaSe Sweden includes all cases registered in the National Prostate Cancer Register (NPCR) of Sweden following a diagnosis of PCa from January 1, 1997, to December 31, 2006. NPCR was started in 1996 in four of the six health care regions in Sweden, and from 1998 on, all regions have participated. The NPCR contains data on tumour characteristics

Results

The PCBaSe Sweden database includes 77 439 men diagnosed with PCa between January 1, 1997, and December 31, 2006, with a mean follow-up time of 3.4 yr (Table 1). Among these men, we identified 128 certain suicides yielding a suicide rate of 48.3 per 100 000 person-years. The corresponding age and standardised suicide rate in the general population was 31.9 per 100 000 person-years, and the expected number of suicides was 84.6 in this cohort, resulting in an SMR of 1.5 (95% CI, 1.3–1.8) (Table 2

Discussion

In this nationwide population-based cohort study of men in PCBaSe Sweden, we found no evidence for an increased risk of suicide among men diagnosed with early nonpalpable PCa detected by PSA testing. The suicide rate, however, was twice as high among men diagnosed with locally advanced or metastatic disease compared with the general male population.

In contrast to our hypothesis, there was no increased suicide risk among men with early nonpalpable T1C tumour detected by means of PSA testing.

Conclusions

We conclude that the increased suicide risk in men with PCa was not due to an increase in the suicide risk for men with PSA-detected tumours. There was an increased risk of suicide for men with advanced and metastatic disease, which is important to acknowledge in order to focus on the need to identify signs of depression and optimise treatment among this category of patients.

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Cited by (88)

Long-term Risks of Depression and Suicide Among Men with Prostate Cancer: A National Cohort Study
2023, European Urology
A diagnosis of prostate cancer (PC) may cause psychosocial distress that worsens quality of life; however, long-term mental health outcomes are unclear.
To determine the long-term risks of major depression and death by suicide in a large population-based cohort.
This was a national cohort study of 180 189 men diagnosed with PC during 1998–2017 and 1 801 890 age-matched, population-based, control men in Sweden.
Major depression and death by suicide were ascertained from nationwide outpatient, inpatient, and death records up to 2018. Cox regression was used to compute hazard ratios (HRs) adjusted for sociodemographic factors and comorbidities. Subanalyses assessed differences by PC treatment during 2005–2017.
Men diagnosed with high-risk PC had higher relative rates of major depression (adjusted HR [aHR] 1.82, 95% confidence interval [CI] 1.75–1.89) and death by suicide (aHR 2.43, 95% CI 2.01–2.95). These associations persisted for ≥10 yr after PC diagnosis. The relative increase in major depression was lower among those treated with radiation (aHR 1.44, 95% CI 1.31–1.57) or surgery (aHR 1.60, 95% CI 1.31–1.95) in comparison to androgen deprivation therapy (ADT) alone (aHR 2.02, 95% CI 1.89–2.16), whereas the relative rate of suicide death was higher only among those treated solely with ADT (aHR 2.83, 95% CI 1.80–4.43). By contrast, men with low- or intermediate-risk PC had a modestly higher relative rate of major depression (aHR 1.19, 95% CI 1.16–1.23) and higher relative rate of suicide death at 3–12 mo after PC diagnosis (aHR 1.88, 95% CI 1.11–3.18) but not across the entire follow-up period (aHR 1.02, 95% CI 0.84–1.25). This study was limited to Sweden and will need replication in other populations.
In this large cohort, high-risk PC was associated with substantially higher relative rates of major depression and death by suicide, which persisted for ≥10 yr after PC diagnosis. PC survivors need close follow-up for timely detection and treatment of psychosocial distress.
In a large Swedish population, men with aggressive prostate cancer had higher long-term relative rates of depression and suicide.
Risk of Depression After Radical Prostatectomy—A Nationwide Registry-based Study
2021, European Urology Oncology
Development of depression in prostate cancer patients depends on multiple disease- and patient-related factors.
To investigate the risk of depression following radical prostatectomy focussing on the impact of surgery and subsequent treatment with salvage radiation or androgen deprivation therapy.
A population-based cohort study of 5570 men who underwent radical prostatectomy in Denmark from 1998 to 2011 was identified in the Danish Prostate Cancer Registry.
Data on covariates and primary outcome defined as a hospital contact for depression or a redeemed antidepressant prescription were obtained from nationwide Danish registries. The risk of depression was evaluated using cumulative incidence functions and Cox models with time since surgery as an underlying time scale. Exposure to salvage procedures was included as time-varying covariates, and analyses were adjusted for confounders.
The cumulative incidence of depression was increased in men who had undergone surgery compared with cancer-free men throughout follow-up of up to 18 yr, particularly among men on androgen deprivation therapy. Compared with no subsequent treatment, the risk of depression was increased with subsequent androgen deprivation therapy (hazard ratio [HR] 1.8, 95% confidence interval [CI] 1.4–2.3), salvage radiation (HR 1.3, 95% CI 1.0–1.6), and the treatments combined (HR 2.2, 95% CI 1.8–2.8) after adjustments for age, year of surgery, income, and cohabitation status. Further adjustment for comorbidity hardly changed the estimates.
Radical prostatectomy and subsequent salvage procedures increase the risk of depression, and men with subsequent androgen deprivation therapy are mainly at risk. Clinicians should thus be aware of depressive symptoms in patients receiving treatment for postsurgical relapse.
In a population-based study, we found that radical prostatectomy and subsequent treatments with either radiation or endocrine manipulation significantly increased the risk of developing clinical depression.
Incidence of suicide death in patients with cancer: A systematic review and meta-analysis
2020, Journal of Affective Disorders
Growing evidence indicated the higher risk of suicide in cancer survivors compared with general population. Our aim is to systematically quantify the extent of suicide death and identify risk factors associated with the incidence of suicide in cancer patients.
We conducted a meta-analysis of relevant studies published in English or Chinese before May 20, 2020. Suicide rate and the number of suicide death were extracted. Our main outcome was suicide rate per 100,000 person-years with 95% CIs using random-effects model.
The pooled incidence of suicide death was 39.72 per 100,000 person-years (95%CI, 33.91–46.52, I ²= 99.6%, P <0 .001). The suicide rate for cancer patients was higher in men (57.78, 95%CI, 47.31–70.56) than in women (14.47, 95%CI, 11.27–18.57). For both sexes combined, esophagus cancer had the highest rate of suicide (87.71, 95%CI, 27.42–280.54). By sex, suicide rates ranked first in males and females were pancreas cancer (195.70, 95%CI, 129.55–295.61) and esophagus cancer (18.34, 95%CI, 5.92–56.84), respectively. The highest suicide rate was 61.02(95%CI, 53.66–69.40) in Asia, and Oceania (24.07, 95%CI, 20.78–27.88) had lowest suicide rate. Suicide rate had a downward trend by years after diagnosis, with the first six months after cancer diagnosis clearly standing out (89.33, 95%CI, 50.64–157.58).
Included studies came from high-income countries and our results might not represent the suicide rate among cancer patients in low- and middle-income countries.
The incidence of suicide among cancer patients was high despite the declined trend recent years, which emphasized psychological health aspects of interventions and perfecting suicide prevention programs.
Distress Screening for Men with Prostate Cancer
2020, Seminars in Oncology Nursing
Although screening for distress and referral to evidence-based psychosocial support is a well-endorsed standard of cancer care, the extent to which this standard has been implemented varies widely. Lack of awareness, knowledge and skills in screening for distress in this patient group are likely key barriers to psychosocial care provision. The objective therefore was to discuss the development, design and evaluation of the effectiveness of the Distress Screening for Prostate Cancer (DSPC) module in targeting the perceived challenges and barriers to distress screening and psychological care by healthcare professionals.
The DSPC module was piloted with five senior prostate cancer specialist nurses prior to the planned implementation with 50 prostate cancer nurses. Their average age was 49.8 years (range 43 to 57 years); there were three females and two males. Results from the Satisfaction with the Distress Screening Prostate Cancer E-Learning Module instrument indicated a high level of overall satisfaction with individual participants' scores ranging from 83-125/125 (mean 108.2).
Distress screening is an essential component of prostate cancer care and based on the information collected from stakeholders an e-learning module was designed and developed as an interactive and engaging evidence-based, pedagogically sound educational platform. The preliminary results from piloting the e-learning module indicated a high level of learner satisfaction and a measurable improvement in pre-post knowledge acquisition scores. These results suggest that this approach has the potential to increase screening for distress in men with prostate cancer and lead to more timely referral to psychosocial and supportive care to improve men's quality of life after diagnosis and over the illness trajectory.
Specialist nurses and other healthcare professionals play an important role in screening men with prostate cancer for distress. This newly designed educational resource supports nurses in their practice of screening men with prostate cancer and the appropriate referral process.
Solid Science for the Upside but Lack of Solid Science for the Downside—Towards Cutting-edge Prostate-cancer Screening
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Quality of Life After Open Radical Prostatectomy Compared with Robot-assisted Radical Prostatectomy
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Citation Excerpt :
Younger men and those treated with adjuvant radiotherapy were especially at risk. Data from the Swedish prostate cancer quality registry (PCBaSe Sweden) showed no increased risk for suicide in men with T1c tumours, but twice as high a risk for suicide among men with locally advanced or metastatic disease compared with an age-matched male population, reflecting the psychological impact the prostate cancer diagnosis may have had [31]. One strength of our study was the use of patient reported data on QoL and functional outcomes through validated questionnaires.
Surgery for prostate cancer has a large impact on quality of life (QoL).
To evaluate predictors for the level of self-assessed QoL at 3 mo, 12 mo, and 24 mo after robot-assisted laparoscopic (RALP) and open radical prostatectomy (ORP).
The LAParoscopic Prostatectomy Robot Open study, a prospective, controlled, nonrandomised trial of more than 4000 men who underwent radical prostatectomy at 14 centres. Here we report on QoL issues after RALP and ORP.
The primary outcome was self-assessed QoL preoperatively and at 3 mo, 12 mo, and 24 mo postoperatively. A direct validated question of self-assessed QoL on a seven-digit visual scale was used. Differences in QoL were analysed using logistic regression, with adjustment for confounders.
QoL did not differ between RALP and ORP postoperatively. Men undergoing ORP had a preoperatively significantly lower level of self-assessed QoL in a multivariable analysis compared with men undergoing RALP (odds ratio: 1.21, 95% confidence interval: 1.02–1.43), that disappeared when adjusted for preoperative preparedness for incontinence, erectile dysfunction, and certainty of being cured (odds ratio: 1.18, 95% confidence interval: 0.99–1.40). Incontinence and erectile dysfunction increased the risk for poor QoL at 3 mo, 12 mo, and 24 mo postoperatively. Biochemical recurrence did not affect QoL. A limitation of the study is the nonrandomised design.
QoL at 3 mo, 12 mo, and 24 mo after RALP or ORP did not differ significantly between the two techniques. Poor QoL was associated with postoperative incontinence and erectile dysfunction but not with early cancer relapse, which was related to thoughts of death and waking up at night with worry.
We did not find any difference in quality of life at 3 mo, 12 mo, and 24 mo when open and robot-assisted surgery for prostate cancer were compared. Postoperative incontinence and erectile dysfunction were associated with poor quality of life.

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Platinum Priority – Prostate CancerEditorial by Bertrand Tombal on pp. 396–397 of this issueSuicide Risk in Men with Prostate-Specific Antigen–Detected Early Prostate Cancer: A Nationwide Population-Based Cohort Study from PCBaSe Sweden

Abstract

Background

Objective

Design, setting, and participants

Measurements

Results and limitations

Conclusions

Introduction

Section snippets

Study population

Results

Discussion

Conclusions

J Urol

Mean sojourn time, overdiagnosis, and reduction in advanced stage prostate cancer due to screening with PSA: implications of sojourn time on screening

Br J Cancer

Clinical characteristics and primary treatment of prostate cancer in Sweden between 1996 and 2005

Scand J Urol Nephrol

Mortality results from a randomized prostate-cancer screening trial

N Engl J Med

Screening and prostate-cancer mortality in a randomized European study

N Engl J Med

Are cancer patients at higher suicide risk than the general population?

Scand J Public Health

Incidence of suicide in persons with cancer

J Clin Oncol

Suicide risk in cancer patients from 1960 to 1999

J Clin Oncol

Suicides among Danish cancer patients 1971–1999

Br J Cancer

Life events and psychosocial factors in elderly suicides—a case-control study

Psychol Med

The prevalence of psychiatric disorders among cancer patients

JAMA

Suicidality in terminally ill Japanese patients with cancer

Cancer

Platinum Priority – Prostate Cancer
Editorial by Bertrand Tombal on pp. 396–397 of this issue
Suicide Risk in Men with Prostate-Specific Antigen–Detected Early Prostate Cancer: A Nationwide Population-Based Cohort Study from PCBaSe Sweden