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.