Interpretation
Some of our research results are very meaningful. Our study showed that patients with Type II epithelial ovarian cancer faced a greater risk of suicidal and accidental mortality which may be attributed to the advanced cancer stage and poor prognosis compared with type I epithelial, germ cell, and sex cord-stromal ovarian cancer16 17. A Danish study containing 2660 cases reported that 78.1% of patients with type II epithelial ovarian cancer diagnosed in late cancer stages, with a median follow-up time of 24 months; as a comparison, only 32.1% of patients with type I epithelial ovarian cancer diagnosed in late cancer stages, with a median follow-up time of 36 months18. Using the SEER database, Edward et al. found that the disease-specific survival of type II is being 64–34% of Type I over the 200-month range16. In the context of the poor prognosis, patients with type II epithelial sarcoma would suffer more psychological concerns, including anxiety and depression. They could feel isolated and hopeless due to the lack of survivor groups. All these may lead to intense suicidal ideation among women with type II epithelial ovarian cancer.
We also found that the risk of suicide was the highest within the first year after initial diagnosis among patients with ovarian cancer. This is a novel finding of the present study, and our results stand corroborated by other cancer studies which showed an elevated risk of suicide within the first year of diagnosis compared with cancer-free controls. Haider et.al reported the highest suicide rates within the first year following diagnosis among women with gynaecologic cancer, with an SMR of 2.88. Further, prior research has shown that significantly higher risks of suicide were observed among patients diagnosed with breast cancer 19, brain cancer20, male genital-system 21, and skin malignant melanoma 22 within the first year of diagnosis. We thought it reasonable as the change from being a healthy individual to being a cancer patient who had a poor prognosis created a new perception of identity. During this process of shift, patients with ovarian cancer often suffer from severe psychological distress and problems in social life 23. This novel finding underlines the concept that healthcare providers should better understand the social psychology and identity changes of newly diagnosed patients with ovarian cancer to better guide ovarian cancer survivors during follow-up. Many methods could be utilized to evaluate the level of mental health and suicidal ideation among cancer patients, such as item 9 of the Patient Health Questionnaire depression module, Centre for Epidemiologic Studies Depression Scale (CES-D), the Impact of Event Scale (IES), and the Profile of Mood States short-form (POMS-SF)24.
Within the ovarian cancer cohort, we observed that those who underwent pelvic exenteration were at the highest risk of suicide. Pelvic exenteration is a radical surgical procedure that removes the visceral pelvic organs including the uterus, tubes, ovaries, parametrium, vagina, urinary bladder, urethra, and rectum, with or without the perineum in an en-bloc fashion2526 27. It is considered the last curative opportunity for malignant gynaecological tumors28. However, it is related to various complications, high costs of substantial treatment, and high mortality. A survey conducted in New Zealand reported 106 complications, such as intra-abdominal collection (43.7%) and wound infection (14.1%), out of a total of 646 consecutive patients who required extended surgery for local advanced pelvic malignancies29. Moreover, severe gastrointestinal and urinary tract symptoms, as well as decreased sexual functions, have also been observed among patients who underwent pelvic exenteration30. These adverse effects and accompanying symptoms had an obvious negative impact on global health status, body image, self-identity, social functioning, emotional response, and quality of life among these survivors31. Therefore, these survivors who underwent pelvic exenteration have an increased risk of suicide and need close monitoring, physicians should be more mindful of these patients to reduce suicidal death.
Ovarian cancer occurs more in patients older than 50 years, similarly, and we found that patients diagnosed over 50 were at higher risk of suicide, especially between the ages of 50-59. Our results stand corroborated by Stephanie’s study which found that female patients with cancer whose age at diagnosis between 55 and 59 had the highest suicide risk among all female cancer survivors 5. Furthermore, it was well recognized that older age was associated with a higher risk of suicide among patients with prostate cancer, lung cancer32, colorectal cancer, and bladder cancer33. The working hypotheses for our finding may be that ovarian cancer patients with older age may suffer more severe emotional and psychological distress. Payne et al. reported that some symptoms, such as the anxiety and depression of recurrent disease and death, as well as sleep disorders, may persist longer in elder patients34. An Australian survey using the Insomnia Severity Index (ISI) to assess the degree of insomnia also confirmed that ovarian cancer patients aged 50-59 present had clinically higher levels of insomnia 35, which has been proven to be correlated with suicidal thoughts and attempts 36. Moreover, older patients could get less information about cancer and psychological support than younger patients from the internet 3738, therefore, they lack the confidence to defeat cancer 39, leading to relatively higher suicidal ideation 40. Given the great difference in suicide risk between young and old survivors with ovarian cancer, it is necessary to regard old patients as a distinctive group that warrants special attention when considering the suicide risk of cancer patients.