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Erryk Katayama*, Selamawit Woldesenbet, Zorays Moazzam, Mary Dillhoff, Aslam Ejaz, Jordan Cloyd, Timothy M. Pawlik
The Ohio State University Wexner Medical Center, Columbus, OH

Introduction: Mental illness (MI) and suicidal ideation (SI) are often associated with a diagnosis of cancer and may contribute to suboptimal outcomes. We sought to define the incidence of MI and SI among patients with gastrointestinal cancers, as well as ascertain patient, clinical, and social determinants of health (SDoH) that were associated with SI.

Methods: Patients diagnosed between 2004-2016 with stomach, liver, pancreatic, and colorectal cancer were identified in the Surveillance, Epidemiology, and End Results-Medicare linked database. County-level social vulnerability index (SVI) was determined using the Centers for Disease Control/Agency for Toxic Substances and Disease Registry, while the Area Health Resource Files were utilized to determine the number of mental health professionals available per 1,000 population. Data was analyzed relative to MI or SI, and multivariable analyses were used to identify factors associated with SI.

Results: Among 382,266 patients (stomach: n=38,430, 10.1%; liver: n=42,393, 11.1%; pancreas: n=68,818, 18.0%; colorectal: n=232,625, 60.9%), 83,514 (21.9%) individuals had a diagnosis of MI (depression: n=25,786, 6.7%, anxiety: n=17,369, 4.5%; depression + anxiety, n=14,375, 3.7%; bipolar disorder, n=11,831, 3.1%; other MI, n=14,153, 3.7%). Overall, 1,410 (0.37%) individuals experienced SI and 359 (0.09%) committed suicide. Compared with patients not receiving active cancer treatment, individuals receiving treatment had an increased risk for SI (OR 1.40, CI 1.17-1.66; p<0.001). Interestingly, SI was least likely among patients with pancreatic cancer (ref: liver cancer; OR 0.67, CI 0.52-0.86; p=0.002), as well as patients with stage III/IV disease (ref: stage I/II; OR 0.59, CI 0.52-067; p<0.001). In contrast, factors most strongly associated with increased SI risk included male sex (OR 1.34, 95% CI 1.19-1.50), White race (OR 1.34, CI 1.13-1.59), and single marital status (OR 2.03, CI 1.81-2.28)(all p<0.001). Of note, compared with patients who resided in counties with high social vulnerability, individuals living in ares with lower SVI had markedly higher risk of SI (OR 1.33, CI 1.14-1.54; p<0.001) (Figure). In addition, living in a county with a shortage of mental health professionals was associated with increased odds of developing SI (OR 1.21, CI 1.04-1.40; p=0.012).

Conclusion: Roughly 1 in 5 patients diagnosed with a gastrointestinal cancer had a MI diagnosis, most often including depression or anxiety. A subset of patients experienced SI with single, white males who lived in areas of relative privilege being most likely to experience SI. Oncology care teams should incorporate routine mental health and SI screening when treating patients with gastrointestinal cancers, and target suicide prevention to those populations at highest risk.

Figure: Predicted probabilites of (a) mental illness and (b) suicidal ideation, relative to social vulnerability index and stratified by race

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