Identify people at risk of self-harm

A cancer diagnosis always causes a psychological and emotional shock that can lead to self-harm. It is a classic but serious manifestation of great need, providing a way out of stress, mental disorders and even despair. Although many studies have focused on the effects of cancer on depression and suicide attempts, this risk remains very difficult to identify and prevent. The psychological consequences go far beyond the mere risk of suicide, as the sometimes serious consequences of self-mutilation in connection with the diagnosis show. However, data on this topic have so far been lacking. The Canadian case-control study published in Jama Oncology (1) came to fill this gap…

A large case-control study on a Canadian registry

The Ontario Cancer Registry (Canada) includes all listed cancers except skin tumors. The study included nearly 807,000 adults newly diagnosed with cancer in 2007 and 2019. Of these, 410,000 had completed at least one Edmonton Self-Assessment Questionnaire (ESAS: Edmonton Symptom Assessment System) within 36 months and 748 had injured themselves (2). Finally, 406 patients had completed a self-questionnaire less than six months prior to self-harm. They were matched to 1624 (4×406) newly diagnosed control cases who had not injured themselves.

Overall, 55% of the subjects are female and 10% come from rural areas. In addition, 6% had self-injured before being diagnosed with cancer. Psychiatric history affects the studied and controlled self-harm cases differently: 9% each versus 3% major psychiatric disorders leading to hospitalization, 7% versus 3% lead to outpatient visits, 48% versus 34% support unknown. On the other hand only 36% of the cases versus 61% of controls had no known history of major psychiatric disorders.

In terms of cancer types and stages, cases and controls are better matched, despite some differences. The methods of cancer treatment also differ significantly: 14% no treatment for self-mutilation versus 5% for controls, 13% for surgery alone versus 4%, 23% combined radiochemotherapy versus 31% and 38% surgery combined with radiotherapy and/or chemotherapy versus 41%

A good risk marker

In this series, the cases studied have moderate to severe symptoms (ESAS score) than the controls. The largest absolute differences relate to the symptoms of anxiety, depression, dry mouth, tiredness and a lack of well-being. The cases also have a significantly higher median ESAS score (4th versus 1), on a scale from 0 to 90 (nine items from 0 to 10).

Based on a univariate analysis, all score symptoms are more frequently severe to moderate in cases. After accounting for severe psychiatric history and cancer treatments, the analysis shows a significant increase in severe to moderate symptoms: 61% for anxiety, 66% for depression, and 65% for shortness of breath. These three disorders are independently associated with an increased risk of self-harm after diagnosis. Finally, each 10-point increment in the ESAS is independently associated with a 50 percent increase in the relative risk of self-harm (RR = 1.51 [1,40-1,63]) within three months.

Identify mental illness

The ESAS score, evaluated shortly after the diagnosis of cancer, proves to be a good tool for screening for the risk of major psychological distress, with the transition to the act of self-mutilation, close the authors. In Ontario, it has long been used almost systematically. However, in clinical practice, even when oncologists are well aware of the issue, preventive psychological interventions remain rare… Let’s hope this study will make a difference It is hoped that these results will encourage the launch of structured psychological support programs after the announcement.

(1) Hallet J. et al. Association of patient-reported outcomes with subsequent nonfatal self-harm following a new cancer diagnosis. JAMA Oncol 2022; doi:10.1001/jamaoncol.2022.0203
(2) Bruera E et al. The Edmonton Symptom Assessment System (ESAS): a simple method for assessing palliative care patients. J Palliate Care. 1991;7(2):6-9. doi:10.1177/082585979100700202

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