Suicide Risk Found to be Significantly High in Head And Neck Cancer, Especially in Rural Populations


Patients with head and neck cancer who live in rural counties are 50% more likely to die from suicide compared with individuals residing in urban or metropolitan areas.

Incidence of death by suicide was found to be significantly high in patients diagnosed with head and neck cancer (HNC), with a 50% higher incidence of suicide-related mortality for those living in rural areas vs urban and metropolitan areas, according to a study published in JAMA Otolaryngology-Head and Neck Surgery.

The suicide mortality rate for patients with HNC living in rural areas was 126.7 per 100,000 person-years compared with 64.0 per 100,000 person-years in urban counties and 59.2 per 100,000 in metropolitan counties. In the general HNC population, investigators identified a notably higher risk of suicide in rural (Standardized mortality ratio [SMR], 5.46: 95% CI, 3.06-9.02), urban (SMR 2.84; 95% CI, 2.13-3.71), and metropolitan populations (SMR 2.78; 95% CI, 2.49-3.09).

“The objective of this study was to estimate suicide incidence and risk among patients with HNC based on rural versus urban or metropolitan residential status. Previous studies have shown that there is higher HNC incidence and mortality among patients from rural areas versus urban areas,” said investigators of the study.

The study used a sample of 134,510 patients with HNC. Of the population, 101,142 (75.2%) had an average age of 57.7 years. Patients in metropolitan areas comprised 86.6% of the study, urban residents were 11.7% and rural was 1.7%.

Within the group, there were 405 reported deaths by suicide. The majority of these patients were non-Hispanic (90.1%) and male (93.1%). Investigators determined the median time from diagnosis to suicide was 26 months (range, 0-203), while the median follow-up time for all patients was 41.0 months (range, 0-203).

Investigators used the unadjusted Fine-Gray models to determine that suicide mortality was highest among rural residents. Patients from urban (HR, 0.51; 95% CI, 0.28-0.92) and metropolitan (HR, 0.48; 95% CI 0.28-0.82) had approximately half the risk of dying by suicide. However, investigators reported that there was no difference in mortality between residents of urban and metropolitan areas (HR, 1.06; 95% CI, 0.78-1.42).

When accounting for covariates, the results were similar. When using the sub-distribuation HR (sdHR), residents of urban (sdHR, 0.52; 95% CI, 0.29-0.94) and metropolitan counties (sdHR, 0.55; 95% CI, 0.32-0.94) had about half the risk of suicide-related mortality vs patients residing within rural counties.

Investigators also used a regression model for inclusion of county-level income and education level and identified a slight decrease in the effect size relative to rural counties ( metropolitan sdHR, 0.62; 95% CI, 0.35-1.09; urban sdHR, 0.55; 95% CI, 0.30-1.00).

Th investigators emphasized the importance of developing a comprehensive understanding of the multilevel factors associated with suicide risk and that future suicide prevention strategies should have increased focus on rural health, quality of life, and mental well-being of survivors, including those with HNC.

“Future suicide prevention policies should have a specific focus on rural health. Although reducing the suicide rate is a national imperative and is considered a leading health indicator in the United States, evidence shows that rural health has not been specifically targeted by the current national strategy for suicide prevention. However, the evidence from the general literature as well as this study of the cancer site with the second-highest suicide mortality rate suggests that it is critical to specifically consider rural health when designing action plans for suicide prevention,” the investigators concluded.


Osazuwa-Peters N, Barnes JM, Okafor SI, et al. Incidence and risk of suicide among patients with head and neck cancer in rural, urban, and metropolitan areas. JAMA Otolaryngol Head Neck Surg. Published Online July 23, 2021. doi:10.1001/jamaoto.2021.1728

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