Article Writeup Premise: You are an MS3 on your internal medicine rotation when your team diagnoses a 60 year

old man with esophageal cancer. You do your best to break the news easily, and he is discharged home after making arrangements for surgical treatment the following week. When you call to follow up a week later, however, his wife informs you that your patient took his own life a few days before. Shaken, you ask your attending how often cancer patients commit suicide after being diagnosed. She points you to a recent study from the NEJM and asks you what you think the team could have done to prevent this tragic outcome. The Study: Fang, et al. Suicide and Cardiovascular Death after a Cancer Diagnosis. N Engl J Med 2012; 366:1310-8. Background: A diagnosis of cancer can be a devastating psychological event, leading to high levels of stress. Previous studies have shown an increased risk of both cardiovascular death and suicide in cancer patients, but most have been interpreted as consequences of treatment or the physiological effect of the disease itself. Studies have yet to look at the period immediately following diagnosis. Question: Are patients at higher risk for suicide and cardiovascular death soon after receiving a diagnosis of cancer? Method: Well-controlled retrospective cohort study Population: 6,073,240 people born in Sweden who were 30 or older between 1991 and 2006. 534,154 of these people were given a first diagnosis of cancer (not covert disease found on autopsy) during this time. All cancer types were included. Intervention: A first diagnosis of cancer. Comparison: No diagnosis of cancer. Outcome: The primary outcome was the relative risk of suicide or cardiac death within various time windows (the first week after diagnosis and various time periods after that up to a year out). Relative risk of suicide in cancer patient vs non-cancer patient was 12.6 (95% CI 8.6-17.8) within the first week and 3.1 (95% CI 2.7 to 3.5) during the first year Relative risk of cardiac death after diagnosis was 5.6 (95% CI 5.2-5.9) within the first week and 3.3 (95% CI 3.1-3.4) within the first month

 Higher risk of suicide for all patients with a psychiatric history or existing CV disease Increased risks declined steadily farther out from the initial cancer diagnosis Both risks were significantly higher for cancers with a worse prognosis (esophagus, liver, pancreas) Comments: Strengths: VERY large cohort (> 6 million), well-controlled -- statistical models were adjusted to control for age at follow-up, sex, calendar period at followup, civil status (cohabitation or not), SES, and educational level; performed case-crossover analysis to account for possible shared causal factors among cancer, CV disease, and suicide. First study to look at the immediate psychological effects of receiving a cancer diagnosis. Weaknesses: Previous psychiatric disease determination was based on hospitalizations, which only captures truly severe cases, so the number of patients with a psych history may have been significantly underestimated (although this would probably be similar between the two groups). Your Answer: Patients are at a significantly higher risk for suicide and cardiovascular death immediately following a cancer diagnosis. I think it would by wise to educate our newly diagnosed cancer patients regarding these risks, as well as making sure they have sources for the social and emotional support they will need in such a difficult time.