Large Proportion of Veteran Survivors of Head and Neck Cancer Who Experience Suicidal Self-Directed Violence Likely to Die


Veteran survivors of head and neck cancer who experienced suicidal self-directed violence were found to most likely die from their injuries.

Findings from a cohort study indicated that a high number of veterans who survived head and neck cancer and experienced suicidal self-directed violence (SSDV) were likely to die due to their injuries.

Within a population of 7803 veterans, 72 had a documented event of SSDV following their diagnosis, 51 of whom died by suicide. Precancer chronic pain (incidence rate ratio [IRR], 2.58; 95% CI, 1.54-4.32) and mood disorders (IRR, 1.95; 95% CI, 1.17-3.24) were both associated with an increased risk of SSDV post cancer, according to findings from 4 adjusted Poisson regression analyses. A higher risk of SSDV was also noted among patients who underwent at least 1 mental health (IRR, 2.73; 95% CI, 1.24-6.03) or substance use disorder (IRR, 3.92; 95% CI, 2.46-6.24) treatment within 90 days of diagnosis. However, a decreased risk of SSVD was noted among patients who had a palliative care encounter (IRR, 0.49; 95% CI, 0.31-0.78) within 90 days of their head and neck cancer diagnosis.

“Identifying precancer and post-cancer risk factors for SSDV is essential to direct prevention efforts in a population that experiences increasing rates of SSDV. The present cohort had an SSDV incidence of 203.9 deaths by suicide and 287.8 SSDV events per 100,000 person-years. This is about 4 times the incidence of suicide compared with veterans with any diagnosed substance use or mental health disorders and 3 times higher than nonveteran [head and neck cancer] survivors,” the study authors wrote.

Investigators utilized data pulled from the U.S. Department of Veteran Affairs in which patients diagnosed with head and neck cancer with documented cancer care in the Veterans Health Administration were identified from January 1, 2012, to January 1, 2018. To establish a cohort of patients with longer expected survivorship, investigators excluded patients with stage IVC disease with a secondary primary cancer or who had disease recurrence within 2 years of diagnosis. Additionally, patients with salivary gland and thyroid cancer as the primary site were excluded from the study due to differences in risk factors and treatment pathways.

Almost all patients included in the study were male (98.4%), with the majority of the population being non-Hispanic White (79.2%). The mean age was 65 years. Moreover, 25.8% of patients were diagnosed with stage I disease, 12.1% were diagnosed with stage II, 15.2% with stage III, and 46.9% with stage IVA or IVB. Patients were most commonly treated with radiation (66.2%), chemotherapy (42.1%), and surgery (37.2%). The most common histology was squamous cell carcinoma (96.1%) and the most common primary tumor sites included pharyngeal (44.0%) and laryngeal (30.3%).

Within the overall patient population, 64.6% of patients had a documented mental health or substance use disorder diagnosis following cancer diagnosis. The most common mental health diagnoses prior to (20.0%) and after (26.2%) head and neck cancer diagnosis were mood disorders, such as major depressive disorder, bipolar disorder, and dysthymia. Additionally, nicotine was the most common substance use disorder prior to (23.7%) and following (24.6%) diagnosis with head and neck cancer diagnosis. Notably, the proportion of patients with mental health or substance use disorder diagnoses increased across all diagnoses from prior to diagnosis (28.2%) to after diagnosis (43.6%). Additionally, 35.2% of survivors were found to suffer from chronic pain 2 years after being diagnosed vs 19.6% prior to being diagnosed.

In total, 28 patients attempted suicide by intentional self-poisoning with different substances resulting in 14 deaths, as well as 33 events of firearm discharge, all of which resulted in death. Moreover, 44.4% of SSDC events took place over 2 years after diagnosis, with 25.0% of individuals experiencing an event within 6 months of being diagnosed. Among the population who had an SSDV event, it was considered to be the first documented SSDV event within their medical history for 93.1% of patients. Those who survived their disease and experienced SSDV were found to have a higher rate of diagnosis of mental health and substance use disorders with the exception of alcohol and nicotine use.

“Determining the best timing to screen for suicidal ideation is important,” the investigators wrote. “Results from this study suggest that the majority of the cohort had their first SSDV event within 2 years of their cancer diagnosis [with a peak at 6 months]. For the majority of those with SSDV, the event following the cancer diagnosis was the first event in their medical record, suggesting that the HNC diagnosis and/or treatment played a role in precipitating the SSDV event.”

Among patients who were treated for a substance use disorder, those who had an SSDV event had a shorter mean time to substance use treatment (92 days) vs those without (137 days). Conversely, those who underwent palliative care with a documented SSDV had a longer mean time to first palliative care treatment (276 days) vs those who did not (172 days).


Nugent SM, Morasco BJ, Handley R, et al. Risk of suicidal self-directed violence among US veteran survivors of head and neck cancer. JAMA Otolaryngol Head Neck Surg. 2021;147(11):981-989. doi:10.1001/jamaoto.2021.2625

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