© 2007 European Society for Medical Oncology
letters to the editor |
Suicide in multiple myeloma and acute myeloid leukaemia
It is well established that persons with cancer commit suicide more frequently than those without [1]. Males generally commit suicide more frequently than females. Head and neck and lung cancer have been associated with a higher risk of suicide. Based on personal clinical experience and the chronic and often devastating character of the disease we postulated that among patients with hematological malignancies, patients diagnosed with multiple myeloma (MM) carried an increased relative risk.Using the Swedish Cancer Registry we identified a total of 24 489 patients with MM and acute myeloid leukemia (AML) diagnosed in Sweden between 1 January 1973 and 31 December 2003 (16 666 with MM and 7 823 with AML). The male-female ratio was 1.17 and 1.02 and the median age 72 and 69 years for MM and AML patients, respectively. Among these patients, 43 suicides were reported to the Swedish Cause of Death Registry. The incidences per 10 000 person years were 6.1 and 8.9 for MM and AML patients, respectively, yielding a standardized mortality ratio (SMR) of 2.35 in MM and 4.58 in AML using the general population as reference. There were more suicides among men (n = 32) than among women (n = 11), but since this is observed also in the general population, the SMR:s for men and women were almost identical (2.69 and 2.62, respectively). The suicide incidence was higher during the first two calendar periods (1973-89; n = 31), with a minor but constant decline in incidence over the study period (Table 1). The suicide SMR was highest during the first two years following diagnosis, but the SMR remained increased even five years after diagnosis. The incidence rate differed little between the age groups. Except for the higher suicide SMR in AML patients, the features described above did not differ between MM and AML (Table 1). Thus, our postulated hypothesis of a higher suicidal rate in MM as compared to the chosen control group of AML patients was not verified. It was consequently of great interest to read in the Journal the recently published article by Kendal [2]. This author analyzed >1.3 million cancer cases in Ontario, Canada diagnosed 1973-2001 from a gender-comparative perspective. In that study a 4.8 times excess in the overall number of male suicides over females was reported. Among females a hematological malignancy (Hodgkin, non-Hodgkin lymphoma, leukemia or MM) was not associated with a relative increased or decreased suicidal rate. However, males with MM showed an increased rate while a decreased relative suicidal rate was observed in male patients with leukemia. AML was not specifically investigated among the leukemias.
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The outcome of patients with MM has improved significantly since 1973, most prominent in patients below the age of 60 years [3]. High-dose melphalan with subsequent autologous stem cell support, thalidomide and a continuous improvement in supportive care probably contribute to this finding [3, 4], which may explain in part the decreasing suicidal rate seen during later calendar periods [1]. The prognosis for patients with AML has however not improved to the same extent, particularly not in patients >60 years [5]. Hopefully, we will be able to improve our understanding of this medical problem among patients with malignant hematological disorders and also better define associated risk factors. Such information is important for hematologists, oncologists and allied health professionals.
1 Department of Medicine, Division of Hematology
2 Department of Medicine, Clinical Epidemiology Unit, Karolinska University Hospital, Stockholm, Sweden
* E-mail: magnus.bjorkholm{at}karolinska.se
References
1. Hem E, Loge JH, Haldorsen T, Ekeberg O. Suicide risk in cancer patients from 1960 to 1999. J Clin Oncol (2004) 22:4209–4216.
2. Kendal WS. Suicide and cancer: a gender-comparative study. Ann Oncol (2007) 18:381–387.
3. Kristinsson S, Landgren O, Dickman PW, Rangert-Derolf Å Björkholm M. Patterns of survival in multiple myeloma: A population-based study of patients diagnosed in Sweden from 1973 to 2003. J Clin Oncol (2007); 25: 1993–1999. Epub 2007 Apr 9.
4. Durie BG. New approaches to treatment for multiple myeloma: durable remission and quality of life as primary goals. Clin Lymphoma Myeloma (2005) 6:181–190.[Web of Science][Medline]
5. Derolf ÅR Landgren O, Dickman P, Kristinsson SY, Björkholm M. Prognosis in acute myeloid leukemia: A population-based study on 5809 patients diagnosed in Sweden 1973-2001. Abstract 1845 (2005) American Society of Hematology Atlanta: Georgia.
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