Cancer

The

n e w e ng l a n d j o u r na l

of

m e dic i n e

original article

Suicide and Cardiovascular Death after a Cancer Diagnosis
Fang Fang, M.D., Ph.D., Katja Fall, M.D., Ph.D., Murray A. Mittleman, M.D., Dr.P.H., Pär Sparén, Ph.D., Weimin Ye, M.D., Ph.D., Hans-Olov Adami, M.D., Ph.D., and Unnur Valdimarsdóttir, Ph.D.

A bs t r ac t
Background
From the Department of MedicalEpidemiology and Biostatistics, Karolinska Institutet, Stockholm (F.F., P.S., W.Y., H.-O.A.); the Clinical Epidemiology and Biostatistics Unit, Örebro University and Örebro University Hospital, Örebro, Sweden (K.F.); the Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (M.A.M.), and the Department of Epidemiology,Harvard School of Public Health (K.F., M.A.M., H.-O.A., U.V.) — all in Boston; and the Center of Public Health Sciences, University of Iceland, Reykjavík (K.F., U.V.). Address reprint requests to Dr. Fang at the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Box 281, 171 77 Stockholm, Sweden, or at fang.fang@ki.se. N Engl J Med 2012;366:1310-8.
Copyright © 2012Massachusetts Medical Society.

Receiving a diagnosis of cancer is a traumatic experience that may trigger immediate adverse health consequences beyond the effects of the disease or treatment.
Methods

Using Poisson and negative binomial regression models, we conducted a historical cohort study involving 6,073,240 Swedes to examine the associations between a cancer diagnosis and the immediate risk ofsuicide or death from cardiovascular causes from 1991 through 2006. To adjust for unmeasured confounders, we also performed a nested, self-matched case-crossover analysis among all patients with cancer who died from suicide or cardiovascular diseases in the cohort.
Results

As compared with cancer-free persons, the relative risk of suicide among patients receiving a cancer diagnosis was 12.6(95% confidence interval [CI], 8.6 to 17.8) during the first week (29 patients; incidence rate, 2.50 per 1000 person-years) and 3.1 (95% CI, 2.7 to 3.5) during the first year (260 patients; incidence rate, 0.60 per 1000 personyears). The relative risk of cardiovascular death after diagnosis was 5.6 (95% CI, 5.2 to 5.9) during the first week (1318 patients; incidence rate, 116.80 per 1000person-years) and 3.3 (95% CI, 3.1 to 3.4) during the first 4 weeks (2641 patients; incidence rate, 65.81 per 1000 person-years). The risk elevations decreased rapidly during the first year after diagnosis. Increased risk was particularly prominent for cancers with a poor prognosis. The case-crossover analysis largely confirmed results from the main analysis.
Conclusions

In this large cohort study,patients who had recently received a cancer diagnosis had increased risks of both suicide and death from cardiovascular causes, as compared with cancer-free persons. (Funded by the Swedish Council for Working Life and Social Research and others.)

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The New England Journal of Medicine Downloaded from nejm.org by DAVID HERNANDEZ GAETA on April4, 2012. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved.

Suicide and Cardiovascular Death after a Cancer Diagnosis

A

large body of evidence suggests high levels of distress and psychiatric symptoms among patients who receive a diagnosis of cancer.1-9 Patients with cancer have been shown to be at increased riskfor suicide10-17 and cardiovascular events.18-22 However, most results have been interpreted to be consequences of treatment or the burden of living with a progressing cancer. The psychological stress induced by the diagnosis itself may also give rise to such serious consequences. However, only a few studies have explored the period immediately after a cancer diagnosis.13,14,23 We recently...