Analysis of the risk of suicide and accidental death in patients with pancreatic cancer in the past 40 years

doi:10.21203/rs.3.rs-1563466/v1

PDF

Research Article

Analysis of the risk of suicide and accidental death in patients with pancreatic cancer in the past 40 years

https://doi.org/10.21203/rs.3.rs-1563466/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted 19 Apr, 2022

You are reading this latest preprint version

Purpose: Data were extracted from the Surveillance, Epidemiology, and End Results (SEER) 18-registry Custom database (1975-2016) to determine the latest risk and risk factors of suicide/accidental death in pancreatic cancer patients.

Methods: SEER*Stat was used to get the Standardized Mortality Ratio (SMR) for suicide/accidental death in pancreatic cancer patients. The Adjusted Risk Ratio (ARR) and risk factors for suicide/accidental death in pancreatic cancer patients were achieved by the multivariate Poisson regression model and multivariate Cox regression model.

Results: Pancreatic cancer patients diagnosed within three months have the highest SMR of suicide (8.52, 95% Confidence Interval [CI]: 5.71-12.24) and accidental death (2.75, 95% CI: 1.98-3.72); Among the pancreatic cancer patients hadn’t performed surgery, patients classified as ‘Recommended but not performed’ have a higher ARR of suicide(3.35, 95% CI: 2.22-4.87) and accidental death(2.12, 95% CI: 1.53-2.87) than patients classified as ‘Not recommended’, the same trend also showed in the multivariate Cox regression model: The Hazard Ratio (HR) of ‘Recommended but not performed’ patients for suicide(Vs ‘Performed’, 2.68, 95% CI: 1.36-5.30) and accidental death(Vs ‘Performed’, 2.68, 95% CI: 1.36-5.30) higher than ‘Not recommended’ patients.

Conclusion: Pancreatic cancer patients have a significantly higher risk of suicide and accidental death than the general population and other cancer patients, especially within three months of diagnosis. In addition, we found in the pancreatic cancer patients who hadn’t performed surgery, those ‘Recommended but not performed’ have a higher risk of suicide and accidental death than those ‘Not recommended’. Therefore, we suggest Department doctors collaborate with oncology psychologists and maintain regular touch with patients who are ‘Recommended but not performed’ and diagnosed within three months.

pancreatic cancer

suicide

survival

SEER

cancer risk factors

Suicide and accidental death have long been a global issue. Every year, over 800,000 people worldwide commit suicide, accounting for 1.5 percent of all deaths(Naghavi 2019). Accidental death is responsible for about 4 to 5 million deaths each year and is the primary cause of disability and death in countries all over the world(Krug, Sharma, and Lozano 2000). Depression, according to H. Bergen et al.(Bergen et al. 2012), maybe a shared risk factor for suicide and accidental death. At the same time, depression is a common psychological burden symptom in cancer patients(Massie 2004), and it has been observed that cancer patients have a significantly higher risk of suicide and accidental death than the general population(Zaorsky et al. 2019). With the advancement of cancer diagnosis and treatment, the proportion of people dying from cancer is actually decreasing, whereas the proportion of people dying from non-cancer causes such as suicide and accidental death is increasing day by day, which cannot be ignored(Zaorsky et al. 2017).

Among many cancers, pancreatic cancer is the seventh leading cause of cancer death worldwide, according to GLOBOCAN estimates for 2018(Bray et al. 2018), and it is expected to become the second leading cause of cancer death worldwide by 2030(Rahib et al. 2014). The course of pancreatic cancer progresses rapidly, and patients’ symptoms are vague and not specific, making early diagnosis difficult. When the symptoms of jaundice become obvious, it indicates that the bile duct has become obstructed, the disease has progressed for at least 3 to 6 months, and the patients have reached the advanced stage of cancer, with the majority of patients being diagnosed in this stage. As a result, the overall prognosis for patients with pancreatic cancer is extremely poor, with a 5-year survival rate of 15–20% and a 10-year survival rate of only 3.9%(Paniccia et al. 2015). According to A. Bill-Axelson, when cancer patients believe there is no cure, this perception can lead to feelings of hopelessness and depression(Bill-Axelson et al. 2010). The phenomenon was indeed more pronounced in patients with pancreatic cancer: A previous clinical study found that 76 percent of pancreatic cancer patients had depressive symptoms before surgery, compared to 20 percent of colon cancer patients(Fras, Litin, and Pearson 1967); Holland et al. found that patients with advanced pancreatic cancer had significantly more depression and mood disorders than patients with other abdominal tumors(Holland et al. 1986); Some studies have even reported prevalence of depression in pancreatic cancer patients is seven times higher than in the general population(Barnes et al. 2018). Given that depression may be a common risk factor for both suicide and accidental death, the risk of suicide and accidental death in pancreatic cancer patients should be taken seriously. To date, only K. K. Turaga et al.(Turaga et al. 2011) reported the risk of suicide among pancreatic cancer patients in 2011 by extracting nearly 10 years of data from 1995 to 2005 using the Surveillance, Epidemiology, and End Results (SEER) database. Given the progress over time, there is a lack of new research on the risk of suicide and accidental death in pancreatic cancer patients. To fill the gap, this study used nearly 40 years of data from 1975 to 2016 to quantify the current risk of suicide and accidental death in patients with pancreatic cancer, as well as identify risk factors for suicide and accidental death.

Based on the foregoing considerations and the previous knowledge reported in other studies, the following questions will be investigated in this study: 1. Risk of suicide/accidental death in pancreatic cancer patients compared to general populations. 2. Risk of suicide/death risk in pancreatic cancer patients compared to other cancers. 3. Risk factors of suicide/accidental death in pancreatic cancer patients.

2.1 Data Sources

Patients diagnosed with cancer between January 1, 1975, and December 31, 2016, were included in this retrospective cohort study, which was based on the National Cancer Institute's SEER all 18 registries database. The SEER database includes nearly 97% of all tumors diagnosed in the United States and covers 28% of the population, which contains detailed records of demographic characteristics, cancer classification, duration of follow-up, and causes of death that can be used to analyze the risk of suicide and accidental death in pancreatic cancer patients and other cancers. Mortality data of the general US population spanning 1975 to 2016 are collected from The National Center For Health Statistics, which can be accessed through the SEER program.

2.2 Study Population and Exclusion criteria

Figure 1 depicted the process of obtaining the final cohort which includes pancreatic cancer patients and other cancer patients through a series of inclusion and exclusion criteria. Among all cancer patients, pancreatic cancer patients were defined by the SEER site recode ICD-O-3 and the rest patients were described as other cancer patients. Patients diagnosed with autopsy or death certificates only (< 10% of patients) and whose SEER histologic stage grouping was unknown were excluded. Simultaneously, we excluded patients with multiple primary cancers (because the cause of suicide in these patients may not be simply because of pancreatic cancer) and those with uncertain surgical status or initial treatment sequence.

2.3 Study variables

Available variables in the SEER database included sex, age at diagnosis, race, marital status, SEER histologic stage, year of diagnosis, sequence of primary treatment, cancer-directed surgery, radiation, and cause of death ['Suicide and self-inflicted injury' (50220) or 'Accidents and adverse effects' (50210)].

In cancer-directed surgery, pancreatic cancer patients were classified as 'Performed', 'Not recommended', and 'Recommended but not performed'. The purpose was to separate patients who did not comply with the doctor’s surgery recommendation for subjective reasons from those who were not recommended for surgery for medical reasons.

The survival time was counted from cancer diagnosis in whole months, and the smallest non-zero value in the survival period is 1. The patients whose survival time was less than one month in the SEER database were recorded as 0, and for these patients, we assign a half-month survival time to them (from 0 to 0.5)according to Standard Epidemiological Practices(Koepsell TD 2003).

2.4 Statistical Analysis

The Chi-square test was used to test differences in baseline characteristics between pancreatic cancer patients and other cancer patients. Statistical indicators about suicide/accidental deaths were obtained through the same statistical analysis process, which is described below (suicide rate or accidental death rate was calculated per 100,000 person-years):

For starters, we focused on the risk of suicides/accidental deaths in the cohort of pancreatic cancer patients: We calculated the Standardized Mortality Ratios (SMR) to indicate the relative risk of suicide/accidental death for pancreatic cancer patients compared to all U.S. residents. After that, the pancreatic cancer patients and other cancer patients were compared in terms of risk of suicide/accidental death (number of events / total person-years) to arrive at a raw Risk Ratio (RR), a multivariate Poisson regression model was used to determine the Adjusted Risk Ratio (ARR) and 95% Confidence Interval (CI) since the dependent variable we were interested in was a small probability event as well as a count variable. The ‘qcc’ R package was used to examine whether the multivariate Poisson regression model excessively deviated. Lastly, the multivariate Cox proportional hazards model was used to determine the risk factors of suicidal/accidental death in pancreatic cancer patients after adjusting pancreatic cancer patients’ baseline characteristics. Meantime, Kaplan–Meier cumulative risk curve of suicide/accidental death in a certain period (monthly count) was plotted according to the ‘cancer-directed surgery’ variable. The multicollinearity between the variables in the Cox model was measured by the Variance Inflation Factor (VIF) using the ‘car’ R package. we also tested the interaction between covariates and the ‘cancer-directed variable surgery’ because the interaction may affect the outcome we are interested in (suicide / accidental death).

All statistical tests were two-sided, and the significance level was set at P < 0.05. Statistical analyses were performed with SEER*Stat version 8.3.9 (Surveillance Research Program, National Cancer Institute, Bethesda, MD) and R version 4.0.5 (R Foundation for Statistical Computing, Vienna, Austria.). This study complied with The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.

3.1 Baseline Characteristics of included Patients

Table 1 shows the baseline characteristics of pancreatic cancer patients and other cancer patients. Overall, the mean (SD; median, IQR) follow-up time of entire cohorts was 70 (79; 41, 10–107) months. Pancreatic cancer patients and other cancer patients were statistically significantly different in all baseline characteristics (all P < 0.05). During the follow-up period (1975–2016), pancreatic cancer patients had 140 (0.08%) suicide deaths and 230 (0.13%) accidental death, while in other cancers patients the corresponding suicide/accidental deaths were 9002 (0.15%) and 30121 (0.52%).

Table 1

Baseline characteristics of patients with pancreatic cancer and other cancers
Characteristic	Patients with Pancreatic cancer (%)		Patients with other cancers (%)	P
Characteristic	N = 166927		N = 5829551	P
Age				< 0.001***
≤ 39		2473 (1.5)	480207 (8.2)
40–64		57280 (34.3)	2482401 (42.6)
≥ 65		107174 (64.2)	2866943 (49.2)
Sex				< 0.05*
Female		84037 (50.3)	2958696 (50.8)
Male		82890 (49.7)	2870855 (49.2)
Race				< 0.001***
White		134225 (80.4)	4765220 (81.7)
Black		19983 (12.0)	595898 (10.2)
Other/Unknown		12719 (7.6)	468433 (8.1)
Marital status				< 0.001***
Married		89247 (53.5)	3171604 (54.4)
Unmarried^†		71696 (43.0)	2263352 (38.8)
Unknown		5984 (3.5)	394595 (6.8)
Stage				< 0.001***
Distant		89195 (53.4)	1242176 (21.4)
Regional		43267 (25.9)	1145058 (19.6)
Localized		14674 (8.8)	2619055 (44.9)
Unstaged/Unknown		19791 (11.9)	823262 (14.1)
Year of diagnosis				< 0.001***
1975–1980		8711 (5.2)	222205 (3.8)
1981–1990		16971 (10.2)	473680 (8.1)
1991–2000		29804 (17.9)	1099575 (18.9)
2001–2010		69299 (41.5)	2584810 (44.3)
2011–2016		42142 (25.2)	1449281 (24.9)
Sequence of primary treatment				< 0.001***
Surgery first		8013 (4.8)	844365 (14.5)
Radiation first		1001 (0.6)	83455 (1.4)
No-treatment		157913 (94.6)	4901731 (84.1)
Surgery				< 0.001***
Performed		28584 (17.1)	3505370 (60.1)
Not recommended		104726 (62.7)	1851812 (31.8)
Recommended but		33617 (20.1)	472369 (8.1)
not performed^‡		33617 (20.1)	472369 (8.1)
Radiation				< 0.001***
Yes		24428 (14.6)	1658912 (28.5)
No/Unknown		142499 (85.4)	4170639 (71.5)
^†: Includes single, widowed, separated, or divorced
^‡: Includes ‘recommended but not performed, patient refused’ or ‘recommended but not performed, Unknown reason’
^P < 0.05, ^P < 0.01, ^**P < 0.001

3.2 Suicide and Accidental Deaths in Pancreatic Cancer patients and General Population

Table 2 shows the risk of suicide/accidental death in pancreatic cancer patients compared to the general population. In general, the SMR of suicide and accidental death in pancreatic cancer patients has the same trend: patients who are older, with non-married status, and had not received cancer-directed surgery ('Not recommended' and 'Recommended but not performed') retain relatively higher SMR. The pre-dominant patients who committed suicide were male (86.43%), white (90%), and patients who did not receive primary treatment (92.86%). Patients with distant metastases (55.71%) had the highest SMR of suicide, 8.94 (95% CI 6.29–12.32, P < 0.05). During the period from diagnosis to suicide, it is obvious that patients within one year of diagnosis have the higher SMR of suicide: 0–3, 8.52 (95% CI 5.71–12.24, P < 0.05); 4–12, 7.53 (95% CI 4.92–11.04, P < 0.05); >12, 2.37 (95% CI 1.32–3.9, P < 0.05).

Table 2

Standardized mortality rates for suicide and accidental deaths in patients with pancreatic cancer and other cancers
Cohort	Suicide deaths					Accident deaths
Cohort	No. of events^†		No. of expected events^‡	SMR (95%CI)^‡		No. of events^†		No. of expected events^‡	SMR (95%CI)^‡
Age
≤ 39	3		0.63		3.19(0.39–11.53)		2	1.65	1.21(0.15–4.38)
40–64	53		5.83		5.49(3.75–7.74)		32	15.09	2.12(1.45–2.99)
≥ 65	84		6.74		5.34(3.74–7.4)		80	41.28	1.94(1.54–2.41)
Sex
Female	19		2.37		5.05(2.61–8.83)		65	33.17	1.97(1.46–2.61)
Male	121		10.82		5.36(4.07–6.93)		49	24.85	1.96(1.51–2.5)
Race
White	126		12.05		5.31(4.09–6.78)		93	48.56	1.92(1.55–2.35)
Black	6		0.53		3.79(0.46–13.7)		12	5.84	2.05(1.06–3.59)
Other/Unknown	8		0.62		6.46(1.76–16.53)		9	3.63	2.48(1.13–4.71)
Marital status
Married	73		9.11		4.06(2.86–5.6)		53	23.82	1.66(1.24–2.17)
Unmarried^§	61		3.61		8.03(5.38–11.54)		53	32.02	2.22(1.67–2.91)
Unknown	6		0.47		8.48(2.31–21.72)		8	2.18	3.67(1.58–7.22)
Stage
Distant	78		4.14		8.94(6.29–12.32)		26	15.64	1.66(1.09–2.44)
Regional	36		5.01		3.39(1.98–5.43)		48	20.44	2.35(1.73–3.11)
Localized	13		2.4		3.33(1.44–6.57)		19	11.99	1.58(0.95–2.47)
Unstaged/Unknown	13		1.65		4.86(2.1–9.57)		21	9.96	2.11(1.31–3.22)
Year of diagnosis
1975–1980	5		1.3		3.84(1.25–8.97)		8	5.51	1.45(0.63–2.86)
1981–1990	13		2.37		5.48(2.92–9.38)		20	9.88	2.02(1.24–3.13)
1991–2000	26		2.93		6.15(3.64–9.71)		25	13.41	1.86(1.21–2.75)
2001–2010	51		4.2		4.76(2.91–7.35)		45	19.3	2.33(1.7–3.12)
2011–2016	45		2.39		5.85(3.2–9.81)		16	9.92	1.61(0.92–2.62)
Sequence of primary treatment
Surgery first	8	1.49			3.37(1.09–7.86)		9	4.97	1.81(0.83–3.43)
Radiation first	2	0.19			5.19(0.13–28.92)		1	0.63	1.58(0.04–8.82)
No-treatment	130	11.52			5.56(4.28–7.1)		104	52.42	1.98(1.62–2.4)
Cancer-directed surgery
Performed	28	5.41			2.77(1.55–4.57)		34	20.34	1.67(1.16–2.34)
Not recommended	82	4.54			7.05(4.82–9.96)		46	21.64	2.13(1.56–2.84)
Recommended but not performed^¶	30	3.25			7.08(4.49–10.62)		34	16.05	2.12(1.47–2.96)
Radiotherapy
Yes	21	3.27			3.97(2.12–6.8)		16	11.36	1.41(0.81–2.29)
No/Unknown	119	9.93			5.74(4.35–7.44)		98	46.66	2.10(1.7–2.56)
Time since diagnosis, months
0–3	67	3.4			8.52(5.71–12.24)		42	15.27	2.75(1.98–3.72)
4–12	41	3.45			7.53(4.92–11.04)		25	14.23	1.76(1.14–2.59)
> 12	32	6.34			2.37(1.32–3.9)		47	28.52	1.65(1.21–2.19)

In terms of accidental death, black patients had a higher SMR than white patients: 2.05 (95% CI 1.06–3.59, P < 0.05) vs. 1.92 (95% CI 1.55–2.35, P < 0.05). Patients with regional spread had a higher SMR than patients with distant metastases: 2.35 (95% CI 1.73–3.11, P < 0.05) vs. 1.66 (95% CI 1.09–2.44, P < 0.05).

3.3 Suicide and Accidental Deaths in Pancreatic Cancer patients and Other Cancers

The Poisson regression model (Table 3) shows the risk of suicide/accidental death in pancreatic cancer patients compared to other cancer patients. The highest ARR of suicide/accidental death were the two time periods of 1975–1980 (13.37, 95% CI 4.66–30.24, P < 0.05) and 1981–1990 (2.58, 95% CI 1.59–3.92, P < 0.05), respectively. After being classified by the 'cancer-directed surgery' variable, in pancreatic cancer patients who are ‘Recommended but not performed’ and ‘Not recommended’, the ARR of suicide is 3.35 (95% CI 2.22–4.87, P < 0.05) and 2.10 (95% CI 1.66–2.62, P < 0.05) respectively. For ARR of accidental death in patients who are ‘Recommended but not performed’ and ‘Not recommended’ are 2.12 (95% CI 1.53–2.87, P < 0.05) and 1.91 (95% CI 1.58–2.29, P < 0.05) in turn.

Table 3

The Poisson regression relative risk model of suicide and accidental death in pancreatic cancer patients diagnosed between January 1, 1975 and December 31, 2016.
Characteristic		Cohort		Suicide deaths				Accident deaths
Characteristic		Cohort		No. of events^†	incidence per 100000 person-years		ARR (95%CI)	No. of events^†	incidence per 100000 person-years	ARR (95%CI)
Age
≤ 39		Pancreatic cancer		3	33.05		1.60 (0.40–4.21)	5	55.09	0.77 (0.28–1.68)
		other cancers		855	17.74		1	1820	37.76	1
40–64		Pancreatic cancer		53	74.54		3.00 (2.25–3.91)	70	98.44	1.41 (1.11–1.77)
		other cancers		3860	22.16		1	9375	53.82	1
≥ 65		Pancreatic cancer		84	113.52		1.77 (1.41–2.20)	155	209.47	2.30 (1.95–2.68)
		other cancers		4287	34.01		1	18926	150.13	1
Sex
Female		Pancreatic cancer		19	23.83		1.19 (0.72–1.84)	106	132.93	1.61 (1.32–1.94)
		other cancers		1778	9.32		1	12995	68.13	1
Male		Pancreatic cancer		121	162.56		2.44 (2.02–2.92)	124	166.59	2.04 (1.70–2.42)
		other cancers		7224	45.81		1	17126	108.59	1
Race
White		Pancreatic cancer		126	102.68		2.30 (1.91–2.74)	190	154.83	2.01 (1.74–2.31)
		other cancers		8271	28.43		1	26191	90.02	1
Black		Pancreatic cancer		6	33.44	7.24 (2.79–15.46)		25	139.34	1.40 (0.91–2.04)
		other cancers		297	9.84		1	2375	78.66	1
Other/Unknown		Pancreatic cancer		8	59.18		0.83 (0.37–1.64)	15	110.96	1.42 (0.81–2.30)
		other cancers		434	15.9		1	1555	56.96	1
Marital status
Married		Pancreatic cancer		73	78.76		2.35 (1.83–2.95)	107	115.44	1.89 (1.55–2.28)
		other cancers		4753	22.71		1	15294	73.06	1
Unmarried^‡		Pancreatic cancer		61	109.78		1.97 (1.50–2.53)	107	192.56	1.79 (1.47–2.15)
		other cancers		3532	30.48		1	12595	108.68	1
Unknown		Pancreatic cancer		6	101.33		2.75 (1.01–6.26)	16	270.21	2.10 (1.22–3.35)
		other cancers		717	30.85		1	2232	96.05	1
Stage
Distant		Pancreatic cancer		78	165.14		2.34 (1.83–2.95)	73	154.55	2.35 (1.84–2.95)
		other cancers		1345	48.35		1	3444	123.81	1
Regional		Pancreatic cancer		36	59.54		1.57 (1.09–2.17)	86	142.23	1.62 (1.29–1.99)
		other cancers		1793	27.18		1	5722	86.73	1
Localized		Pancreatic cancer		13	42.75		3.24 (1.78–5.35)	39	128.25	1.62 (1.16–2.19)
		other cancers		4505	20.59		1	17096	78.13	1
Unstaged/Unknown	Pancreatic cancer		13		80.89		2.84 (1.55–4.72)	32	199.1	1.62 (1.11–2.25)
		other cancers		1359	37.91		1	3859	107.64	1
Year of diagnosis
1975–1980		Pancreatic cancer		5	78.39	13.37 (4.66–30.24)		8	125.42	1.46 (0.65–2.79)
		other cancers		576	27.34		1	1875	89	1
1981–1990		Pancreatic cancer		13	100.3		4.05 (2.20–6.78)	20	154.31	2.58 (1.59–3.92)
		other cancers		1253	29.54		1	3990	94.07	1
1991–2000		Pancreatic cancer		26	95.77		4.50 (2.96–6.50)	38	139.97	1.60 (1.14–2.17)
		other cancers		2343	26.15		1	7926	88.46	1
2001–2010		Pancreatic cancer		51	72.5		1.98 (1.47–2.59)	104	147.84	2.01 (1.65–2.43)
		other cancers		3777	23.65		1	13063	81.79	1
2011–2016		Pancreatic cancer		45	120.51		1.69 (1.22–2.27)	60	160.68	1.65 (1.26–2.11)
		other cancers		1053	29.54		1	3267	91.64	1
Sequence of primary treatment
Surgery first		Pancreatic cancer		8	42.03		1.10 (0.66–1.72)	17	89.3	1.05 (0.62–1.63)
		other cancers		934	14.98		1	3437	55.14	1
Radiation first		Pancreatic cancer		2	86.76		1.45 (0.50–3.27)	5	216.9	2.61 (0.91–5.85)
		other cancers		180	31.82		1	471	83.27	1
No-treatment		Pancreatic cancer		130	97.87		2.15 (1.79–2.56)	208	156.58	1.98 (1.72–2.26)
		other cancers		7888	28.13		1	26213	93.47	1
Cancer-directed surgery
Performed		Pancreatic cancer		28	38.88		1.51 (1.02–2.15)	70	97.21	1.47 (1.15–1.85)
		other cancers		5407	20.2		1	19673	73.51	1
Not recommended		Pancreatic cancer		82	132.33		2.10 (1.66–2.62)	118	190.42	1.91 (1.58–2.29)
		other cancers		2569	42.4		1	7700	127.1	1
Recommended but not performed^§		Pancreatic cancer		30	148.53		3.35 (2.22–4.87)	42	207.95	2.12 (1.53–2.87)
Recommended but not performed^§		other cancers		1026	50.67		1	2748	135.72
Radiotherapy
Yes		Pancreatic cancer		21	58.36		2.09 (1.31–3.14)	33	91.71	1.47 (1.02–2.04)
		other cancers		2378	23.42		1	7310	71.98	1
No/Unknown		Pancreatic cancer		119	100.68		1.87 (1.66–2.11)	197	166.68	1.97 (1.71–2.26)
		other cancers		6624	26.83		1	22811	92.39	1

3.4 Risk factors of Suicide and Accidental Death in Pancreatic Cancer patients

Table 4 shows the risk factors for suicide/accidental death in pancreatic cancer patients identified by multivariate Cox regression. In pancreatic cancer patients’ variables, gender, marital statuses, and cancer-directed surgery (hazard ratio [HR] for ‘Recommended but not performed’ vs. ‘Performed’ = 2.68, 95%CI 1.36–5.30 and 2.16, 95% CI 1.32–3.55 for suicide and accidental death respectively, both P < 0.05) were shared risk factors of suicide and accidental death. Race (HR for ‘Whites’ vs. ‘Blacks’ = 3.06, 95% CI 1.34–6.98, P < 0.01) was an important risk factor for suicide. Age at diagnosis (HR for ‘≥ 65’ vs. ‘≤ 39’ = 3.86, 95% CI 1.39–10.69, P < 0.05), sequence of primary treatment (HR for ‘Radiation first’ vs. ‘No-treatment’ = 5.76, 95% CI 1.91–17.37, P < 0.05; HR for ‘Surgery first’ vs. ‘No-treatment’ = 2.28, 95% CI 1.01–5.17, P < 0.05) and radiotherapy (HR for ‘No/Unknown’ vs. ‘Yes’ = 2.73, 95% CI 1.46–5.10, P < 0.01) were important risk factors of accidental death.

Table 4

The multivariate Cox proportional hazard model diagnosed from January 1, 1975 to December 31, 2016 was used for suicide and accidental death of patients with pancreatic cancer.
Cohort	Suicide deaths							Accident deaths
Cohort	HR (95%CI)			P				HR (95%CI)			P
Age
≤ 39	Ref.	-						Ref.		-
40–64	1.18(0.37–3.8)		0.78					2.07(0.74–5.76)					0.17
≥ 65	1.64(0.51–5.3)		0.4					3.86(1.39–10.69)							< 0.01**
Sex
Female	Ref.	-						Ref.		-
Male	7.79(4.75–12.78)					< 0.001***	1.49(1.14–1.96)					< 0.01**
Race
White	3.06(1.34–6.98)			<0.01**			1.12(0.73–1.71)						0.6
Black	Ref.	-					Ref.		-
Other/Unknown	2.01(0.70–5.83)			0.2			0.87(0.45–1.65)						0.66
Marital status
Married	Ref.	-					Ref.		-
Unmarried^†	2.03(1.43–2.88)			< 0.001***			1.61(1.21–2.15)							< 0.001***
Unknown	1.56(0.67–3.60)			0.3			2.24(1.32–3.82)							< 0.01**
Stage
Distant	1.79(0.96–3.33)			0.06			0.78(0.51–1.19)							0.26
Regional	1.12(0.59–2.13)			0.73			1.16(0.78–1.71)							0.47
Localized	Ref.	-					Ref.		-
Unstaged/Unknown	0.93(0.42–2.07)			0.87			0.89(0.54–1.45)							0.63
Year of diagnosis
1975–1980	Ref.	-					Ref.		-
1981–1990	1.51(0.54–4.25)				0.44		1.53(0.64–3.63)							0.34
1991–2000	1.88(0.68–5.19)				0.22		1.58(0.67–3.71)							0.29
2001–2010	1.44(0.52–3.96)			0.48			1.88(0.81–4.35)							0.14
2011–2016	1.92(0.68–5.39)			0.22			1.97(0.83–4.70)							0.12
Sequence of primary treatment
Surgery first	1.57(0.57–4.33)			0.39			2.28(1.01–5.17)							< 0.05*
Radiation first	3.07(0.63–14.87)				0.16		5.76(1.91–17.37)							<0.01**
No-treatment	Ref.	-					Ref.		-
Cancer-directed surgery
Performed	Ref.	-					Ref.		-
Not recommended	1.75(1.01–3.03)			< 0.05*			1.89(1.29–2.76)							<0.01**
Recommended but not performed^‡	2.68(1.36–5.30)			<0.01**			2.16(1.32–3.55)							<0.01**
Radiotherapy
Yes	Ref.	-					Ref.		-
No/Unknown	1.65(0.87–3.13)			0.12			2.73(1.46–5.10)							< 0.01**
^†: Includes single, widowed, separated, or divorced
^‡: Includes ‘recommended but not performed, patient refused’ or ‘recommended but not performed, Unknown reason’
^P < 0.05, ^P < 0.01, ^**P < 0.001

Figure 2 and Fig. 3 show the cumulative risk of suicide/accidental death in pancreatic cancer patients grouped by the variable of ‘cancer-directed surgery’. The patients who are ‘Recommended but not performed’ have the highest cumulative risk of suicide/accidental death, the following are ‘Not Recommended’ and ‘Performed’ (log-rank test, all P < 0.001).

With advances in medical technology, cancer patients are living longer, but their risk of non-cancer death is increasing due to the increasing incidence of mental illness(Zaorsky et al. 2017). Among numerous cancers, mental illness is more prevalent in pancreatic cancer patients, therefore, it is necessary to explore the risk of non-caner death in them. In this study, 5,996,478 pancreatic cancer patients and other cancer patients were extracted from the 1975–2016 SEER 18-REGISTRY dataset to elaborate on the risk of suicide/accidental death between pancreatic cancer patients and the general population/other cancer patients. The research results demonstrate that pancreatic cancer patients had a significantly higher risk of suicide and accidental death than the general population. To account for the baseline differences between the general population and cancer patients, we also compared pancreatic cancer patients to other cancer patients and observed that pancreatic cancer patients had a higher risk of suicide and accidental death. Finally, after adjusting for patient characteristics, we conclude that the suicide risk factors include male, white, unmarried, and patients who had not received surgery, while accidental death's risk factors include those 65 and older, male, unmarried, and those who had priority surgery or radiation therapy, as well as those who had not received surgery.

In 2011, K. K. Turaga et al.(Turaga et al. 2011) utilized the SEER dataset to extract data for almost 10 years (from 1995 to 2005) to report on the risk of suicide in pancreatic cancer patients. The findings revealed that males and unmarried were risk factors for suicide in pancreatic cancer patients, which matched our findings. Furthermore, their findings indicated that the risk of suicide in males with pancreatic cancer was around 11 times greater than in the general population, but our findings revealed that the risk of suicide in men with pancreatic cancer was only 5 to 6 times higher. Besides, we also observed that surgery and race had a role in the suicide of pancreatic cancer patients. These discrepancies are most likely attributable to methodological variances and sample inclusion and exclusion criteria. In comparison to the study by k. K. Turaga et al., this study included more samples and considered more confounding factors, resulting in more credible results. Besides that, we also discuss pancreatic cancer patients' accidental deaths, elaborating on pancreatic cancer patients’ non-cancer death risk in more detail.

As shown in Table 2 and Table 3, pancreatic cancer patients whose age ≥ 40 have a higher risk of suicide/accidental death than those whose age < 40. Among patients age ≥ 40, particularly those whose age between 40–64, the risk of suicide is 5 times more than the general population and 3 times more than other cancer patients. Cox regression analysis showed that age was not an influencing factor for suicide but accidental death, which may be because pancreatic cancer spreads quickly and early diagnosis is difficult, most individuals are diagnosed after they reach old age. (As can be seen from Table 1, pancreatic cancer patients under 40 years old account for only 1.5% of the total population, while those over 65 years old account for 64.2%). Those old patients are more likely to have problems concentrating, organ damage, mobility difficulties, and other medical complications, all of which are associated with an increased risk of accidental injury(Yang et al. 2020); at the same time, few of them have access to the Internet, which means they are less likely to have access to adequate information about pancreatic cancer on the Internet, which could lead them to ineffective or even harmful decisions(Bass et al. 2006) and may increase their risk of accidental death. Therefore, it is suggested to initiate voluntary activities or establish support groups to regularly enhance knowledge related to pancreatic cancer for these patients, so that they can have a correct and objective understanding of their disease, reduce the needless stress generated by a lack of background information about the illness, and boost their confidence in their ability to overcome it.

Race is the influencing factor of suicide, which may be linked to the socioeconomic situation, social background, educational attainment, and other factors(Ivey-Stephenson et al. 2017). Priority treatment, particularly priority radiation therapy, is a substantial risk factor for pancreatic cancer patients' accidental death, which may be connected to radiation therapy's adverse effects. In patients with head and neck cancer, radiation treatment has been proven to cause cognitive impairment, which may raise the chance of death by accident(Yang et al. 2020).

Table 4 shows that gender and marital statuses are shared influencing factors of suicide and accidental death in pancreatic cancer patients. Male with pancreatic cancer had a greater risk of suicide and accidental death than females, while a study of suicide and accidental death among bone tumors patients found a similar difference(Yu et al. 2021). However, we think the fundamental reasons for gender variations in the risk of suicide and accidental death are due to undiscovered confoundings factors (such as income, lifestyle, and family structure). Marital status has an important influence on a person’s psychological status: the research by Noquez revealed that widower, single, and divorced pancreatic cancer patients had a higher burden of symptoms, such as pain, exhaustion, sadness, anxiety, and soma(Noquez 2008). Studies have also shown that emotional support from a spouse reduces the risk of accidental death(Cubbin, LeClere, and Smith 2000), illustrating the importance of a partner for pancreatic cancer patients. In addition to providing emotional and spiritual support, a partner of a pancreatic cancer patient can also serve as the patient's caregiver by helping the patient accept medical advice, informing family members about the disease promptly, and communicating with experts about treatment options.

According to the results shown in Table 2 and Table 3, we found an interesting trend: the SMR of suicide and accidental death is 8.52 and 2.75 respectively in pancreatic cancer patients within the first three months after diagnosis, significantly higher than another period. Similarly, A cohort study from Japan also found a significant increase in the risk of suicide and accidental death in the first six months after cancer diagnosis, especially in the first month(Harashima et al. 2021). This might be because the stage of cancer diagnosis is a significant stressor that has a direct influence on the likelihood of patients’ behavior of suicide or accidental death. At the same time, such stressors will also place a huge emotional burden on patients, which will lead to patients no longer actively receiving treatment, such as not following the treatment advice of experts, increasing difficulties in communicating with health workers, etc, which will lead to an increased risk of suicide and accidental death in patients with pancreatic cancer. Therefore, we urge physicians to focus on the psychological status of patients within three months of diagnosis of pancreatic cancer, and oncologists also need to enhance the frequency of communication with these patients, which has been shown to play an indispensable role in suicide prevention(Trevino et al. 2014).

Another interesting finding is according to the ‘cancer-directed surgery’ variable, the variable was classified as ‘performed’, ‘not recommended’, and ‘recommended but not performed’. Among patients who did not undergo surgery, patients classified as ‘recommended but not performed’ have the highest risk of suicide, followed by ‘not recommended’. To validate the results, we also plotted Kaplan–Meier cumulative risk curve of suicide/accidental death in a certain period (monthly count), which was classified according to 'cancer-directed surgery' for pancreatic cancer patients' variable, with results consistent with previous: patients classified as ‘recommended but not performed’ have the highest risk of suicide (Log-rank test, p < 0.01). The above conclusion tells us should attach importance to those who can accept surgery, especially in part because of the subjective reason they refused surgery patients (referred to as ‘recommended but not performed’). In reality, more than one-third of pancreatic cancer patients are unable to accept radical surgery owing to the fast advancement of the disease, if we can successfully persuade ‘recommended but not performed’ patients, according to our results, will significantly reduce pancreatic cancer patients’ risk of suicide in overall. Therefore, we propose the following treatment suggestions for the medical worker: First, General Practitioners (GPs) and emergency physicians should maintain regular contact with patients who reject their doctors' surgery recommendations. The weeks leading up to a suicide attempt are a critical time for patients who are suicidal to communicate with their primary care physician and the emergency room, according to research(Laanani et al. 2020). Through frequent communication, medical staff can learn more about these patients, which may help to find out why they reject surgical recommendations. Second, seek the help of a clinical psychologist. A study from SEER-Medicine showed that pancreatic cancer patients with a history of depression were 22 percent less likely to have cancer-guided surgery(Paredes et al. 2021). This shows that these patients have more psychological troubles, and clinical psychology can timely help these patients relieve the psychological and spiritual pressure. Increased collaboration between clinical psychologists and pancreatic cancer professionals is expected to improve patients' emotional and physical well-being. Clinical practice guidelines also offer a similar view: end-of-life psychological therapies may greatly enhance patients' moods and help them to better regulate their bodily functions to deal with the ensuing changes(Kaya et al. 2003). Third, health care workers should always pay attention to the use of psychotropic drugs in this group of patients. If the psychotropic drug utilization rate is high, it can be regarded as a sign that the burden of psychological symptoms of patients is heavy and in urgent need of relief. A pancreatic cancer cohort study from Denmark also revealed that patients who did not receive surgery were more likely to begin using antidepressants(Dengsø et al. 2020).

As mentioned earlier, only a subset of pancreatic cancer patients have conditions that allow them to undergo radical surgery. For most patients with pancreatic cancer who cannot receive radical treatment, the best choice of treatment for them is radiotherapy, chemotherapy, and targeted therapy combined with palliative treatment. Palliative care can manage patients' symptoms well, whereas patients with pancreatic cancer often have a symptom burden involving multiple organs due to the anatomical position of the pancreas. A randomized controlled trial study on pancreatic cancer also showed that a combination of palliative care is critical for improving the prognosis of patients with pancreatic cancer(Woo et al. 2019). The main symptoms of pancreatic cancer patients are pain and depression. The incidence of pain is about 70–80%, manifested as severe upper abdominal pain, but also extends to the back, patients can not lie flat and normal eating, only curled up. Besides damage to physical function and psychological integrity, pain is also associated with overall survival and quality of life in pancreatic cancer patients. Therefore, controlling pain is essential for reducing the risk of suicide/accidental death for pancreatic cancer patients. Palliative treatment is one of the most effective treatments for controlling pain, it has been reported that palliative radiotherapy has a good regulation effect on the symptom burden of pancreatic cancer patients, and most pancreatic cancer patients can get great relief of pain after palliative treatment(Ebrahimi, Rasch, and van Tienhoven 2018). The American Society of Clinical Oncology (AASC) clinical practice guidelines also recommend that patients with metastatic pancreatic cancer receive palliative care as early as possible to relieve symptoms of pain, preferably at the time of diagnosis(Sohal et al. 2018). At present, pain relief methods mainly include drugs and surgery. When it comes to drug treatment, the World Health Organization (WHO) recommends that patients take these three actions to alleviate pain("World Health Organization. WHO’s cancer pain ladder for adults. 2014"): first, take non-opioid drugs (such as aspirin and paracetamol) by mouth immediately, and if no relief is achieved, then take mild opioids (such as codeine), or try a strong opioid (such as morphine) if it still does not meet expectations; In surgical therapy, The most effective procedure so far is celiac plexus release, which relieves approximately 70 to 90 percent of the pain in patients with pancreatic cancer(Wyse et al. 2011).

Depression is another major symptom of pancreatic cancer patients. Nearly half of pancreatic cancer patients are reported to experience psychiatric symptoms (depression, anxiety, etc.) before diagnosis(Fras, Litin, and Pearson 1967; Green and Austin 1993). This suggests that there may be some biological mechanism between depression and pancreatic cancer, Andrew D. Boyd et al(Boyd and Riba 2007) reviewed the studies on the biological mechanism between pancreatic cancer and depression, but no conclusion has been reached so far. Whether there is any mechanism between pancreatic cancer and depression, it is a fact the prevalence of depression in pancreatic cancer patients is significantly higher than that in other cancer patients(Massie 2004; Fras, Litin, and Pearson 1967; Holland et al. 1986). Meanwhile, depression is the shared risk factor for suicide and accidental death, we think it plays a non-negligible role in reducing the risk of suicide/accidental death in pancreatic cancer patients. One of the most direct ways to reduce depression is taking antidepressants, which have been shown to improve symptoms and quality of life in patients with pancreatic(Purohit et al. 1978). Among the many antidepressants, selective serotonin reuptake inhibitors (SSRIs) are recommended because they are well tolerated and have few side effects, including fluoxetine, fluvoxamine, and citalopram. In addition to antidepressants, psychological interventions such as meditation, yoga, and acupuncture are also effective in alleviating depression in pancreatic cancer patients(Luo et al. 2014). In practice, health care workers can also refer to the treatment of depression in pancreatic cancer patients proposed by Walker and Sharpe(Walker and Sharpe 2009), who provide practical treatment measures from multiple aspects of education, medication, and behavior.

Although our study has revealed several important findings related to the risk of suicide and accidental death in patients with pancreatic cancer, limitations remain. To begin with, it is difficult to make an accurate distinction between suicide and accidental death when registering causes of death, especially in the case of poisoning or gunshot wounds, different coroners who see such scenes are more likely to have different judgments on the classification of cause of death; Additionally, the SEER database lacks records related to patients' mental disorders and quality of life, which may confound the real association between pancreatic cancer patients and risk of suicide/accidental death.

The study showed that pancreatic cancer patients had a higher risk of suicide and accidental death than not only the general population but also other cancer patients. Notably, we also found the first three months after diagnosis is a critical period for medical workers takes action to reduce the risk of suicide/accidental death in pancreatic cancer patients. Among the pancreatic cancer patients who had not performed surgery, we noticed ‘recommended but not performed’ patients have a higher risk of suicide/accidental death than ‘not recommended’ patients. Therefore, we suggest that for patients diagnosed within three months or classified as 'recommended but not performed', specialists need to work with cancer psychologists, and frequently pay attention to their psychological status.

AASC

American Society of Clinical Oncology

ARR

Adjusted Risk RatioCI:Confidence Interval

GPs

General Practitioners

Hazard Ratio

Risk Ratio

SEER

Surveillance, Epidemiology, and End Results

STORE

Strengthening the Reporting of Observational Studies in Epidemiology

SMR

standardized mortality ratio

SSRIs

Selective Serotonin Reuptake Inhibitors

VIF

Variance Inflation Factor

WHO

World Health Organization

5.1 Acknowledgments

The authors thank the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries for creating the SEER database and the research conditions provided by the Department of Biostatistics, School of Public Health, Harbin Medical University.

5.2 Author contributions

Ye Tian participated in the research design, carried out the statistical analyses, interpreted the results, screened data, and wrote the first draft of the paper manuscript. Yan Liu and Fan Wang participated in the research design, interpreted the results, and revised the manuscript. Zonghui Wang, Ruojin Li, and Rui Zheng participated in the research design and interpreted the results. All contributors reviewed the manuscript and provided valuable comments.

5.3 Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

5.4 Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

5.5 Data Availability

The datasets generated during and/or analysed during the current study are available in the SEER repository, https://seer.cancer.gov/about/overview.html.

5.6 Ethical approval

This is an observational study. The Harbin Medical University Research Ethics Committee has confirmed that no ethical approval is required.

Barnes, Adam F., Theresa P. Yeo, Benjamin Leiby, Abigail Kay, and Jordan M. Winter. 2018. 'Pancreatic Cancer-Associated Depression: A Case Report and Review of the Literature', Pancreas, 47: 1065–77.
Bass, Sarah Bauerle, Sheryl Burt Ruzek, Thomas F. Gordon, Linda Fleisher, Nancy McKeown-Conn, and Dirk Moore. 2006. 'Relationship of Internet health information use with patient behavior and self-efficacy: experiences of newly diagnosed cancer patients who contact the National Cancer Institute's Cancer Information Service', Journal of health communication, 11: 219–36.
Bergen, H., K. Hawton, N. Kapur, J. Cooper, S. Steeg, J. Ness, and K. Waters. 2012. 'Shared characteristics of suicides and other unnatural deaths following non-fatal self-harm? A multicentre study of risk factors', Psychological medicine, 42: 727 – 41.
Bill-Axelson, Anna, Hans Garmo, Mats Lambe, Ola Bratt, Jan Adolfsson, Ullakarin Nyberg, Gunnar Steineck, and Pär Stattin. 2010. 'Suicide risk in men with prostate-specific antigen-detected early prostate cancer: a nationwide population-based cohort study from PCBaSe Sweden', European urology, 57: 390 – 95.
Boyd, Andrew D., and Michelle Riba. 2007. 'Depression and pancreatic cancer', Journal of the National Comprehensive Cancer Network: JNCCN, 5: 113–16.
Bray, Freddie, Jacques Ferlay, Isabelle Soerjomataram, Rebecca L. Siegel, Lindsey A. Torre, and Ahmedin Jemal. 2018. 'Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries', CA: a cancer journal for clinicians, 68: 394–424.
Cubbin, C., F. B. LeClere, and G. S. Smith. 2000. 'Socioeconomic status and the occurrence of fatal and nonfatal injury in the United States', American journal of public health, 90: 70–77.
Dengsø, Kristine Elberg, Elisabeth Wreford Andersen, Thordis Thomsen, Carsten Palnæs Hansen, Bo Marcel Christensen, Jens Hillingsø, and Susanne Oksbjerg Dalton. 2020. 'Increased psychological symptom burden in patients with pancreatic cancer: A population-based cohort study', Pancreatology: official journal of the International Association of Pancreatology (IAP) … et al.], 20: 511–21.
Ebrahimi, Gati, Coen R. N. Rasch, and Geertjan van Tienhoven. 2018. 'Pain relief after a short course of palliative radiotherapy in pancreatic cancer, the Academic Medical Center (AMC) experience', Acta oncologica (Stockholm, Sweden), 57: 697–700.
Fras, I., E. M. Litin, and J. S. Pearson. 1967. 'Comparison of psychiatric symptoms in carcinoma of the pancreas with those in some other intra-abdominal neoplasms', The American journal of psychiatry, 123: 1553–62.
Green, A. I., and C. P. Austin. 1993. 'Psychopathology of pancreatic cancer. A psychobiologic probe', Psychosomatics, 34: 208–21.
Harashima, Saki, Maiko Fujimori, Tatsuo Akechi, Tomohiro Matsuda, Kumiko Saika, Takaaki Hasegawa, Keisuke Inoue, Kazuhiro Yoshiuchi, Isao Miyashiro, Yosuke Uchitomi, and Yutaka J Matsuoka. 2021. 'Death by suicide, other externally caused injuries and cardiovascular diseases within 6 months of cancer diagnosis (J-SUPPORT 1902)', Japanese journal of clinical oncology, 51: 744–52.
Holland, J. C., A. H. Korzun, S. Tross, P. Silberfarb, M. Perry, R. Comis, and M. Oster. 1986. 'Comparative psychological disturbance in patients with pancreatic and gastric cancer', The American journal of psychiatry, 143: 982–86.
Ivey-Stephenson, Asha Z., Alex E. Crosby, Shane P. D. Jack, Tadesse Haileyesus, and Marcie-Jo Kresnow-Sedacca. 2017. 'Suicide Trends Among and Within Urbanization Levels by Sex, Race/Ethnicity, Age Group, and Mechanism of Death - United States, 2001–2015', Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C.: 2002), 66.
Kaya, M., T. Baran, M. Asan-Ozusaglam, Y. S. Cakmak, K. O. Tozak, A. Mol, A. Mentes, and G. Sezen. 2003. 'Clinical practice guidelines for the psychosocial care of adults with cancer (2003)', Journal of the National Comprehensive Cancer Network Jnccn, 1: 14.
Koepsell TD, Weiss NS. 2003. Epidemiologic Methods: Studying the Occurrence of Illness (Oxford University Press: New York, NY).
Krug, E. G., G. K. Sharma, and R. Lozano. 2000. 'The global burden of injuries', American journal of public health, 90: 523–26.
Laanani, Moussa, Claire Imbaud, Philippe Tuppin, Claire Poulalhon, Fabrice Jollant, Joël Coste, and Grégoire Rey. 2020. 'Contacts with Health Services During the Year Prior to Suicide Death and Prevalent Conditions A Nationwide Study', Journal of affective disorders, 274: 174–82.
Luo, Jia, Jie Jane Chen, Carl Deguzman, Karen Mustian, Megan Insco, George Fisher, and Oxana Palesh. 2014. 'Symptoms and palliative care needs of pancreatic adenocarcinoma patients', Journal of palliative medicine, 17: 640–41.
Massie, Mary Jane. 2004. 'Prevalence of depression in patients with cancer', Journal of the National Cancer Institute. Monographs: 57–71.
Naghavi, Mohsen. 2019. 'Global, regional, and national burden of suicide mortality 1990 to 2016: systematic analysis for the Global Burden of Disease Study 2016', BMJ (Clinical research ed.), 364: l94.
Noquez, A.E. 2008. 'Cancer-related symptom clusters (Doctoral dissertation)', Retrieved from ProQuest Dissertation and Theses Database (Publication No. AAT 3314979).
Paniccia, Alessandro, Patrick Hosokawa, William Henderson, Richard D. Schulick, Barish H. Edil, Martin D. McCarter, and Csaba Gajdos. 2015. 'Characteristics of 10-Year Survivors of Pancreatic Ductal Adenocarcinoma', JAMA surgery, 150: 701–10.
Paredes, Anghela Z., J. Madison Hyer, Diamantis I. Tsilimigras, Elizabeth Palmer, Maryam B. Lustberg, Mary E. Dillhoff, Jordan M. Cloyd, Allan Tsung, Aslam Ejaz, Sharla Wells-Di Gregorio, and Timothy M. Pawlik. 2021. 'Association of pre-existing mental illness with all-cause and cancer-specific mortality among Medicare beneficiaries with pancreatic cancer', HPB: the official journal of the International Hepato Pancreato Biliary Association, 23: 451–58.
Purohit, D. R., P. L. Navlakha, R. S. Modi, and R. Eshpumiyani. 1978. 'The role antidepressants in hospitalised cancer patients. (A pilot study)', The Journal of the Association of Physicians of India, 26: 245–48.
Rahib, Lola, Benjamin D. Smith, Rhonda Aizenberg, Allison B. Rosenzweig, Julie M. Fleshman, and Lynn M. Matrisian. 2014. 'Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States', Cancer research, 74: 2913–21.
Sohal, Davendra P. S., Erin B. Kennedy, Alok Khorana, Mehmet S. Copur, Christopher H. Crane, Ignacio Garrido-Laguna, Smitha Krishnamurthi, Cassadie Moravek, Eileen M. O'Reilly, Philip A. Philip, Ramesh K. Ramanathan, Joseph T. Ruggiero, Manish A. Shah, Susan Urba, Hope E. Uronis, Michelle W. Lau, and Daniel Laheru. 2018. 'Metastatic Pancreatic Cancer: ASCO Clinical Practice Guideline Update', Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 36: 2545–56.
Trevino, Kelly M., Caroline H. Abbott, Michael J. Fisch, Robert J. Friedlander, Paul R. Duberstein, and Holly G. Prigerson. 2014. 'Patient-oncologist alliance as protection against suicidal ideation in young adults with advanced cancer', Cancer, 120: 2272–81.
Turaga, Kiran K., Mokenge P. Malafa, Paul B. Jacobsen, Michael J. Schell, and Michael G. Sarr. 2011. 'Suicide in patients with pancreatic cancer', Cancer, 117: 642 – 47.
Walker, Jane, and Michael Sharpe. 2009. 'Depression Care for People with Cancer: a collaborative care intervention', General hospital psychiatry, 31: 436 – 41.
Woo, Sang Myung, Mi Kyung Song, Meeyoung Lee, Jungnam Joo, Dae Hyun Kim, Jong-Heun Kim, Sung-Sik Han, Sang-Jae Park, Tae Hyun Kim, and Woo Jin Lee. 2019. 'Effect of Early Management on Pain and Depression in Patients with Pancreatobiliary Cancer: A Randomized Clinical Trial', Cancers, 11.
"World Health Organization. WHO’s cancer pain ladder for adults. 2014." In.
Wyse, Jonathan M., Marco Carone, Sarto C. Paquin, Mariana Usatii, and Anand V. Sahai. 2011. 'Randomized, double-blind, controlled trial of early endoscopic ultrasound-guided celiac plexus neurolysis to prevent pain progression in patients with newly diagnosed, painful, inoperable pancreatic cancer', Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 29: 3541–46.
Yang, Kunyu, Yongqiang Zheng, Jiangtong Peng, Jiayuan Chen, Huayi Feng, Kaixu Yu, Ying Chen, Wenjing Luo, Pengcheng Yang, Yun Yang, and Bian Wu. 2020. 'Incidence of Death From Unintentional Injury Among Patients With Cancer in the United States', JAMA network open, 3: e1921647.
Yu, Kaixu, Bian Wu, Ying Chen, Honglei Kang, Kehan Song, Yimin Dong, Renpeng Peng, and Feng Li. 2021. 'Suicide and accidental deaths among patients with primary malignant bone tumors', Journal of bone oncology, 27: 100353.
Zaorsky, N. G., T. M. Churilla, B. L. Egleston, S. G. Fisher, J. A. Ridge, E. M. Horwitz, and J. E. Meyer. 2017. 'Causes of death among cancer patients', Annals of oncology: official journal of the European Society for Medical Oncology, 28: 400–07.
Zaorsky, Nicholas G., Ying Zhang, Leonard Tuanquin, Shirley M. Bluethmann, Henry S. Park, and Vernon M. Chinchilli. 2019. 'Suicide among cancer patients', Nature communications, 10: 207.

No competing interests reported.

PDF

Version 1

posted 19 Apr, 2022

You are reading this latest preprint version

Analysis of the risk of suicide and accidental death in patients with pancreatic cancer in the past 40 years

Status:

Version 1

Abstract

Figures

1 Introduction

2 Materials And Method

2.1 Data Sources

2.2 Study Population and Exclusion criteria

2.3 Study variables

2.4 Statistical Analysis

3 Results

3.1 Baseline Characteristics of included Patients

3.2 Suicide and Accidental Deaths in Pancreatic Cancer patients and General Population

3.3 Suicide and Accidental Deaths in Pancreatic Cancer patients and Other Cancers

3.4 Risk factors of Suicide and Accidental Death in Pancreatic Cancer patients

4 Discussion

Abbreviations

Declarations

5.1 Acknowledgments

5.2 Author contributions

5.3 Funding

5.4 Competing Interests

5.5 Data Availability

5.6 Ethical approval

References

Competing Interests

Status:

Version 1