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Incidence and Risk of Suicide Among Patients With Head and Neck Cancer in Rural, Urban, and Metropolitan Areas

Educational Objective
To calculate the suicide incidence among patients with head and neck cancer in rural vs urban or metropolitan areas.
1 Credit CME
Key Points

Question  Do the incidence and risk of suicide among patients with head and neck cancer differ by rural vs urban or metropolitan residence status?

Findings  In this population-based cross-sectional study, the suicide mortality rate among patients with head and neck cancer was 59, 64, and 127 per 100 000 person-years among residents of metropolitan, urban, and rural counties, respectively. In competing-risk Fine-Gray proportional hazards models accounting for covariates, the suicide risk was nearly 2 times higher for residents of rural counties.

Meaning  This study suggests that suicide incidence is elevated in general among patients with head and neck cancer but is markedly higher for patients living in rural areas.


Importance  Patients with head and neck cancer (HNC) are known to be at increased risk of suicide compared with the general population, but there has been insufficient research on whether this risk differs based on patients’ rural, urban, or metropolitan residence status.

Objective  To evaluate whether the risk of suicide among patients with HNC differs by rural vs urban or metropolitan residence status.

Design, Setting, and Participants  This cross-sectional study uses data from the Surveillance, Epidemiology, and End Results database on patients aged 18 to 74 years who received a diagnosis of HNC from January 1, 2000, to December 31, 2016. Statistical analysis was conducted from November 27, 2020, to June 3, 2021.

Exposures  Residence status, assessed using 2013 Rural Urban Continuum Codes.

Main Outcomes and Measures  Death due to suicide was assessed by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes (U03, X60-X84, and Y87.0) and the cause of death recode (50220). Standardized mortality ratios (SMRs) of suicide, assessing the suicide risk among patients with HNC compared with the general population, were calculated. Suicide risk by residence status was compared using Fine-Gray proportional hazards regression models.

Results  Data from 134 510 patients with HNC (101 142 men [75.2%]; mean [SE] age, 57.7 [10.3] years) were analyzed, and 405 suicides were identified. Metropolitan residents composed 86.6% of the sample, urban residents composed 11.7%, and rural residents composed 1.7%. The mortality rate of suicide was 59.2 per 100 000 person-years in metropolitan counties, 64.0 per 100 000 person-years in urban counties, and 126.7 per 100 000 person-years in rural counties. Compared with the general population, the risk of suicide was markedly higher among patients with HNC in metropolitan (SMR, 2.78; 95% CI, 2.49-3.09), urban (SMR, 2.84; 95% CI, 2.13-3.71), and rural (SMR, 5.47; 95% CI, 3.06-9.02) areas. In Fine-Gray competing-risk analyses that adjusted for other covariates, there was no meaningful difference in suicide risk among urban vs metropolitan residents. However, compared with rural residents, residents of urban (subdistribution hazard ratio, 0.52; 95% CI, 0.29-0.94) and metropolitan counties (subdistribution hazard ratio, 0.55; 95% CI, 0.32-0.94) had greatly lower risk of suicide.

Conclusions and Relevance  The findings of this cross-sectional study suggest that suicide risk is elevated in general among patients with HNC but is significantly higher for patients residing in rural areas. Effective suicide prevention strategies in the population of patients with HNC need to account for rural health owing to the high risk of suicide among residents with HNC in rural areas.

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Article Information

Accepted for Publication: June 9, 2021.

Published Online: July 23, 2021. doi:10.1001/jamaoto.2021.1728

Corresponding Author: Nosayaba Osazuwa-Peters, BDS, PhD, MPH, CHES, Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, 40 Duke Medicine Cir, Duke South Yellow Zone 4080, DUMC 3805, Durham, NC 27710-4000 (nosa.peters@duke.edu).

Author Contributions: Drs Osazuwa-Peters and Barnes had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Osazuwa-Peters, Barnes, Okafor, Simpson.

Acquisition, analysis, or interpretation of data: Osazuwa-Peters, Barnes, Okafor, Taylor, Hussaini, Adjei Boakye, Graboyes, Lee.

Drafting of the manuscript: Osazuwa-Peters, Barnes, Okafor.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Barnes, Hussaini, Adjei Boakye.

Administrative, technical, or material support: Osazuwa-Peters, Okafor, Hussaini.

Supervision: Osazuwa-Peters, Simpson, Lee.

Conflict of Interest Disclosures: Dr Graboyes reported receiving grants from the National Cancer Institute and the Doris Duke Charitable Foundation outside the submitted work. No other disclosures were reported.

Disclaimer: Drs Osazuwa-Peters and Graboyes are members of the editorial board of JAMA Otolaryngology–Head & Neck Surgery, but they were not involved in any of the decisions regarding review of the manuscript or its acceptance.

Meeting Presentation: This article was presented at the 10th International Conference of the American Head and Neck Society; July 23, 2021; Chicago, Illinois.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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