Army Veteran Jim Altman receives lung cancer screening facilitated by CT technologist, Miguel Santiago at the C.W. Bill Young VAMC in Bay Pines, FL. A new study suggests that the best time to offer palliative care is after a diagnosis of advanced lung cancer. (VA photo)

PORTLAND, OR — Much of the focus on suicide at the VA is on recently discharged servicemembers who suffer from conditions such as depression or post-traumatic stress disorder (PTSD).

A new study looks, however, at an entirely different cohort of veterans at increased risk of taking their own lives: those with advanced lung cancer.

Research presented this spring at ATS 2018, the American Thoracic Society’s annual meeting, reported that, among 20,900 lung cancer patients in a VA cancer registry, 30 committed suicide. That rate was more than five times greater than the average in veterans of a similar age, according to the presentation.1

A solution, according to the study team from the Center to Improve Veteran Involvement in Care at the Portland VAMC and Oregon Health & Science University, could be appropriate palliative care.

“Suicide is a significant national public health problem, especially among lung cancer patients and among veterans,” explained lead author Donald R. Sullivan, MD, MA, core investigator at the Center to Improve Veteran Involvement in Care at the Portland VA and member of the OHSU Knight Cancer Institute. “We wanted to see if palliative care, which has been shown to improve quality of life, reduced suicides among veterans with stage IIIB and IV lung cancer.”

Sullivan added that “the risk of suicide is underappreciated among cancer patients, especially those with advanced stage disease.”

To reach those conclusions, the study team examined records for advanced stage lung cancer patients (IIIB & IV) in the VA Healthcare System diagnosed from January 2007- December 2013. VA data sources including inpatient, outpatient and fee-basis encounter data, as well as the Central Cancer Registry and the Suicide Data Repository, all were analyzed.

For the study, patients were considered to have died by suicide if cause of death (COD) was listed as ICD9-CM (E950.x) or ICD10-CM (X60-X84). Incidence rates of suicide were calculated from the number of cancer patients at risk (from year of diagnosis to year of death) and the number of suicides in each year.

Documenting whether a specialty palliative care encounter occurred after a lung cancer diagnosis. Investigators were able to gauge association between palliative care and suicide as COD.

Overall, among 20,900 lung cancer patients, 87% had lung cancer as COD, with other common causes including other cancers, heart disease, and chronic obstructive pulmonary disease (COPD).

Suicide was the cause of 30 deaths, data indicated, with the overall rate calculated as 200 per 100,000 patient years vs. 37.5 per 100,000 patient years among veterans of similar age, sex and year who use VA healthcare.

“Interestingly, only 20% (6/30) of the patients who died by suicide had a palliative care encounter compared to 57% among lung cancer patients with another non-suicide COD,” study authors pointed out. They determined that a palliative care encounter was associated with and 82% lower likelihood of death from suicide (OR=0.18, 95% CI: 0.07-0.46, p<0.001).

Background information in the article noted that palliative care seeks to relieve physical pain and discomfort, as well address psychological issues, such as anxiety, that diminish quality of life for those with life-threatening illnesses. Furthermore, the study emphasized that palliative care should be patient-centered, allowing patients to determine care preferences and to make advance care planning decisions.

The research is touted as the first to explore the relationship between palliative care and suicide risk in cancer patients.

Sullivan described how, while several medical societies recommend palliative care for all patients with advanced stage lung cancer, it occurs much less often than it should in real-world practice.

“There are many barriers to palliative care, and unfortunately, some are related to clinician referrals,” he suggested. “Not all doctors are aware of the benefits of palliative care.”

Sullivan, added, however that the VA has initiatives to help educate physicians about palliative care and encourage them to refer patients to those services. “I think the VA is doing a better job than other healthcare systems, but there is still room for improvement,” he said.

The optimal time to offer palliative care is upon receiving a diagnosis of advanced lung cancer, Sullivan said, explaining, “The best scenario is an integrated approach, in which patients with serious illness receive palliative care along with disease-modifying therapies like chemotherapy at the same time,” he said.

Study authors said limitations to their research, which also was printed in the American Journal of Respiratory and Critical Care Medicine, included a small sample size and lack of information about suicide attempts and substance abuse. They added that results might not be generalizable to women, because they are underrepresented in the VA health care system.

“Veterans with lung cancer are at high risk for completed suicide. Palliative care was associated with a reduced risk of death by suicide,” the study authors concluded. “Benefits of palliative care, such as improved symptom control and quality of life, may manifest in improved survival, if they reduce the subsequent risk of suicide among patients with lung cancer. Further research into the potential benefit of palliative care on suicide risk in cancer patients is warranted.”

1Sullivan D, Forsberg CW, Golden SE, Dobscha SK, et. Al. Incidence of Suicide and Potential Benefits of Palliative Care Among Patients with Lung Cancer. American Journal of Respiratory and Critical Care Medicine 2018;197:A4167.