Abstract
Despite substantial progress in cancer therapy in recent decades, patients with cancer remain at high suicide risk. Data from individual studies have not been comprehensively quantified and specific risk factors are ill-defined. We assessed suicide mortality risk according to cancer prognosis, stage, time since diagnosis, gender, ethnicity, marital status, year of recruitment and geographic region. We searched EMBASE, MEDLINE, PsycINFO, Web of Science, CINAHL and Google Scholar for relevant articles up to February 2021. We used a random effects model, performed meta-regression meta-analysis and assessed heterogeneity and publication bias using I², funnel plots and Egger’s and Begg’s tests. We performed a systematic review including 62 studies and 47,035,065 patients. To avoid patient sample overlap, the meta-analysis was performed on 28 studies, involving 22,407,690 patients with cancer. Suicide mortality was significantly increased compared with the general population (standardized mortality ratio = 1.85, 95% confidence interval = 1.55–2.20). Risk was strongly related to cancer prognosis, cancer stage, time since diagnosis and geographic region. Patients with cancer, particularly those with specific risk factors, should be closely monitored for suicidality and need specialized care to reduce short- and long-term risks of suicide.
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Data availability
Data in the published article (and its Supplementary Information) have been presented where possible in aggregated form. Data from primary studies are publicly available within the databases listed in Supplementary Information. The datasets generated and/or analyzed during the current study are available from C.S. (by mail at Corinna.Seliger-Behme@med.uni-heidelberg.de) upon reasonable request as part of a scientific collaboration with adherence to standards of good scientific practice, although restrictions may apply due to privacy reasons and ongoing research projects. Data sharing will require a Materials Transfer Agreement (MTA) and is limited to noncommercial use. Requests will be answered within 4 weeks.
Code availability
All codes were adapted using R software, v.4.0.2 and v.4.1.1. Data sheets were created using Microsoft Excel v.16.57. The codes that support the findings of this study are available from the corresponding author (C.S.) (by mail at Corinna.Seliger-Behme@med.uni-heidelberg.de) upon reasonable request as part of a scientific collaboration with adherence to standards of good scientific practice, although restrictions may apply due to privacy reasons and ongoing research projects. Data sharing will require an MTA and is limited to noncommercial use. Requests will be answered within 4 weeks.
Change history
01 July 2024
In the version of the article initially published, ref. 8 included the wrong volume number and page range, leading to an incorrect Google Scholar link. This has now been amended.
20 March 2023
A Correction to this paper has been published: https://doi.org/10.1038/s41591-023-02307-6
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M.H. was responsible for conceptualization, data curation, formal analysis, investigation, methodology, project administration, resources, software, validation, visualization and writing (original draft and writing, review and editing). L.H. was responsible for conceptualization, data curation, investigation, resources and writing (review and editing). H.J. was responsible for conceptualization, data curation, formal analysis, investigation, methodology, resources, software, supervision, validation, visualization and writing (review and editing). P.K. was responsible for conceptualization and writing (review and editing). H.K. performed conceptualization, investigation, resources and writing (review and editing). M.L. was responsible for conceptualization, methodology, supervision and writing (review and editing). C.S. performed conceptualization, investigation, methodology, resources, project administration, supervision, validation and writing (review and editing).
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Extended data
Extended Data Fig. 1 Forest plot of individual cancer sites of all studies included in the (A) systematic review and (B) meta-analysis, by magnitude of risk estimate.
ISR2 = 98.86% and IMA2 = 99.03%, P-heterogeneity<0.0001. Abbreviations: SMR, standardized mortality ratio; CI, confidence interval; ISR2, I2-statistic for systematic review; IMA2, I2-statistic for meta-analysis. Squares depict SMR point estimates and error bars their corresponding 95% confidence intervals.
Extended Data Fig. 2 Forest plot of random effects meta-analysis including 62 cohort studies of suicide in cancer patients extracted from all databases.
Studies are listed by magnitude of risk estimate and weighted by their contribution to the summary risk estimate. I2 = 99.55%, P-heterogeneity<0.0001. Abbreviations: SMR, standardized mortality ratio; CI, confidence interval; MF, men and women combined; M, men only; F, women only; RE, risk estimate. Squares depict SMR point estimates and error bars their corresponding 95% confidence intervals.
Extended Data Fig. 3 Summary forest plot of cancer sites, by prognosis based on 62 studies.
Good prognosis was defined as a 5-year survival rate of >90%; medium prognosis was defined as a 5-year survival rate of 50–90%; poor prognosis was defined as a 5-year survival rate of <50%. I2 = 99.00%, P-heterogeneity<0.0001. Abbreviations: SMR, standardized mortality ratio; CI, confidence interval; n, number of studies included in the analysis; cancer sites with n = 1 were not included in the analysis.
Extended Data Fig. 4 Summary forest plot of subgroup analyses of suicide in patients with cancer based on 62 studies.
Abbreviations: SMR, standardized mortality ratio; CI, confidence interval; n, number of studies included in the analysis.
Extended Data Fig. 5 Funnel plot of random effects meta-analysis including 62 risk estimates of suicide in cancer patients.
Two-sided P-value for Begg’s test = 0.42; Two-sided P-value for Egger’s test = 0.4239.
Extended Data Fig. 6 Suicide rates in the general population of countries included in the present meta-analysis, except Taiwan (data not available).
Data presented by country, from 1950 to 2005.
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Heinrich, M., Hofmann, L., Baurecht, H. et al. Suicide risk and mortality among patients with cancer. Nat Med 28, 852–859 (2022). https://doi.org/10.1038/s41591-022-01745-y
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