Older, white males with advanced bladder cancer at high risk for suicide

Older, single white males with advanced bladder cancer have the highest suicide risk among those with other cancers of the male genitals and urinary system, researchers report.

Genitourinary cancers – prostate, bladder, kidney, testis, and penile cancer – comprise nearly 25 percent of all new cancers diagnosed in the United States. A new study in the journal Cancer appears to be the first assessment of this group of patients’ suicide risks, said Dr. Zachary Klaassen, urology resident at the Medical College of Georgia at Georgia Regents University and GRHealth.

The review identified suicide in these patients as a public health dilemma that needs physician awareness, particularly in patients who are older, male, and have aggressive disease.

“The older, white, single male is already at higher risk in the general society for suicide; add on the fact that he has advanced bladder cancer, and this is a high-risk patient,” said Klaassen, the study’s corresponding author. “But this has taught me that we have to look for warning signs in all these patients.”

“It’s a tough situation. We have to talk more with our patients about how they are feeling even if it’s uncomfortable for us,” said Dr. Martha K. Terris, Chief of the MCG Section of Urology, Chief of Urology at the Charlie Norwood Veterans Affairs Medical Center, and the study’s senior author.

The surgeons acknowledge the rigorous road faced by many of these patients and the respect they have for them. Those with bladder cancer, for example, often have surgery to both remove their diseased bladder and divert urine to a collection bag at their side. Recovery from this major procedure takes about three months; interferes initially with bowel function; can result in ongoing problems such as leakage and infection; and patients need long term, close follow up for signs of metastasis, so it’s also a very expensive cancer to treat. However, caught early, cure is possible, especially if the disease is not super aggressive. “It absolutely is treatable. You see the patient who comes in 20 years later with no evidence of disease,” Klaassen said.

Klaassen, Terris, and their colleagues perused the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program, or SEER, database from 1988-2010 to find 1.2 million people with genitourinary cancer, examining variables such as age, sex, race, as well as disease and treatment aggressiveness.

They found that bladder cancer patients across the board, whether or not they had surgery or advanced disease, had a higher suicide risk than patients with other genitourinary cancers. Older patients with bladder, prostate, and testis cancer were generally at an increased risk. When looking specifically at the black population, those with bladder cancer also had the highest suicide rates; however, those with bladder, prostate, and kidney cancer had much lower suicide rates than whites in the group. Prostate cancer patients had an increased suicide risk over time, with the highest rate 15 years or more after their diagnosis.

Increased age is associated with increased risk of suicide in general as well as in patients with cancer, note Drs. Marie B. Tobin and Gary D. Steinberg, from the University of Chicago Department of Psychiatry and Behavioral Neuroscience and Section of Urology, respectively, in an accompanying editorial.

The Chicago investigators also note that unprecedented new cancer treatments make it even more important to “attend to the whole patient and specifically to patient suffering.” Information provided by the MCG investigators can help cancer physicians and surgeons “prevent what could well be viewed as the ultimate treatment failure.”

The average age of diagnosis of bladder cancer is 73, and about nine out of 10 patients with bladder cancer are over age 55, according to the American Cancer Society. Bladder cancer is more common in men and smokers, with about 74,000 new cases annually in this country and more than a half million survivors. Suicide is the 10th leading cause of death in the United States; cancer is number two, according to the Centers for Disease Control and Prevention.

Suicide rates in the general population are trending upward, with a current rate estimated at 12.6 deaths per 100,000 annually. In the review, bladder cancer patients’ overall suicide risk was 2.7 times higher; rates were 1.86 times higher in kidney cancer patients, 1.27 times higher in prostate cancer, 1.23 times higher in testicular cancer, and 0.96 times higher in penile cancers.

The MCG doctors want to look again at these patient groups, this time also looking for signs of prior psychiatric problems and treatment, such as antidepressants, to get a more inclusive picture. They already know bladder cancer patients, for example, often have other smoking-related disease such as chronic obstructive pulmonary disease that leaves them constantly short of breath.

Newer bladder cancer treatments include robotic surgery that reduces recovery time and blood loss when the bladder is removed and, in younger, otherwise healthy patients with good muscle tone, using intestines to create a new bladder that is connected to the urethra so patients urinate more naturally. Advances in understanding the genetics and biology of the diseases hold future promise, Klaassen said. Prostate cancer is the most common genitourinary cancer followed by bladder cancer.