Boosting support for people with cancer who are at high risk of suicide

Public Health England's examination of patients’ cause of death highlights the need for robust emotional support in the first six months after diagnosis

Public Health England's examination of patients’ cause of death highlights the need for robust emotional support in the first six months after diagnosis

Picture: iStock

The findings are stark: people with a cancer diagnosis are at 20% higher risk of taking their own lives, according to a Public Health England (PHE) 2018 study.

The research – presented at PHE’s Cancer services, data and outcomes conference in June – identified around 2,500 patients whose cause of death was recorded as death by suicide or an open verdict. The findings were collected over a 20-year period after analysing Office for National Statistics data and the PHE’s national cancer register. It equated to 0.08% of all deaths.

Emotional support vital

Public Health England cancer lead
Jem Rashbass

PHE cancer lead Jem Rashbass says the findings highlight the need for good emotional support, particularly in the first six months after diagnosis. ‘Receiving a cancer diagnosis can be devastating. Health professionals play a vital role in offering emotional support to cancer patients at the most difficult time.

‘It’s important that they recognise the signs of depression, especially when their patient may often have many other physical needs.’

RCN cancer and breast care forum chair Susanne Cruickshank agrees, but says it is also important to recognise which cancers have the highest risk of death by suicide.

Highest risk

The study identified five types of cancer that have the highest risk:

  • Mesothelioma.
  • Pancreatic.
  • Oesophageal.
  • Lung.
  • Stomach.

Mesothelimoa has the highest risk – 4.5 times greater than average – followed by pancreatic cancer at 3.9 times.


of cancer survivors experience a psychological issue ten years after treatment

Source: Public Health England (2018)

Poor prognosis

‘These cancers have the poorest prognosis,’ says Dr Cruickshank. ‘The diagnoses tend to come late and there are fewer options for treatment.

‘We need to look at the pathway for these patients and what better support they can be given.

‘We need to be careful about looking at cancers differently. For example, it’s a different picture for breast or colorectal cancers.’

RCN cancer and breast care forum
chair Susanne Cruickshank
Picture: Tim George

Macmillan chief nursing officer Karen Roberts says part of the solution may lie in ‘reframing’ the way cancers are communicated.

‘The cancer may be incurable, but that does not mean it isn't treatable. That individual may no longer be able to think about their lives in the next 20 or 30 years.

Ideally placed

‘But they still have a short-term and can think about what they want to do with the years they do have left such as seeing their child finish school. Cancer nurse specialists are ideally placed to help with this.’

Macmillan chief nursing officer
Karen Roberts.
Picture: David Gee

This research is not the first time the higher risk of death by suicide has been noted. A number of previous studies have also made the link and the need for emotional support for cancer patients is well established – and not just immediately after diagnosis. Coping with the side effects of treatments – such as chemotherapy and radiotherapy and end of life – are also crucial.

Even surviving cancer is no guarantee. More than half of people with cancer are found to experience at least one psychological issue a decade after treatment, according to Macmillan Cancer Support.

Meanwhile, a study published in the journal Cancer last year found one fifth of patients experience what could be called post-traumatic stress disorder.

The NHS has long-established guidelines for dealing with emotional distress with the National Institute for Health and Care Excellence (NICE) (2004) recommending four different levels of support that all staff should provide through to the roles of specialist staff.

National Institute for Health and Care Excellence’s four-tier model of psychological support

Level one

All health and care staff expected to be able to recognise psychological needs and give general support, information and communicate compassionately.

Level two

Expert staff, such as clinical nurse specialists, should be able to screen for psychological distress using standardised screening tools such as the distress thermometer and depression scale.

Level three

Trained and accredited professionals should be available to provide assessments and then counselling and other interventions, such as anxiety management and solution-focused therapy.

Level four

Mental health specialists should be available to provide diagnosis of serious problems and provide psychological and psychiatric interventions, such as cognitive behavioural therapy.

(Source: NICE (2004) Guidance on cancer services. Improving supportive and palliative care for adults with cancer)


UK Oncology Nursing Society board
member elect Mark Foulkes
Picture: Neil O’Connor

The problem is that the support is not always available. UK Oncology Nursing Society board member elect Mark Foulkes, the lead cancer nurse at Royal Berkshire NHS Foundation Trust, describes it as ‘very patchy’.

Access to clinical nurse specialist

He says a main problem is that not every patient has access to clinical nurse specialists and other senior nurses, who are likely to have been given training, while the wider cancer team, such as chemotherapy nurses, cancer ward nurses and doctors in oncology medicine, do not always have the ‘required skills and time’.

‘We need to make sure there is greater access and consistency in training for the wider multidisciplinary team.’

One in ten

cancer patients need specialist psychological or mental health support

Source: Public Health England (2018)

But he says ensuring patients who need it can get help from psychological specialists and core mental health services is also essential as there will be ‘complex cases that require greater skills and psychological support’ than core staff can provide.

RCN professional lead for mental
health Catherine Gamble
Picture: Barney Newman 

‘Crucial gap in pathway’

Approximately 10% of patients will need higher level (three and four) psychological support.

But RCN professional lead for mental health Catherine Gamble says this is where there is a crucial ‘gap in the pathway’.

Despite the emergence of new roles, such as advanced practitioners and consultant nurses in mental health and psychiatry liaison teams, too many hospitals are not able to help people with cancer access that expert support.

‘Patients do not get the preventive care they need. It means they are left contacting crisis care teams when things get bad. There just isn’t the pathway to get them into mental healthcare when they need it.’

‘We provide counselling to get patients to accept their situation’ 

Janice Rees is one of two Macmillan clinical psychologists at the Cardiff and Vale University Health Board.

The posts were created 3.5 years ago to provide extra support to cancer patients who had more complex psychological problems than could be dealt with by cancer doctors and nurses as well as to provide support and training to those staff.

The posts are part-funded by Macmillan and receive around 130 referrals a year.

‘Struggle with diagnosis’

Ms Rees works part-time and says: ‘We provide counselling. It is focused on getting patients to accept their situation and working on their strengths and skills to cope.

'Some people struggle with diagnosis, for others it is the consequences of treatment, which can be pretty hard to cope with, and then there are people who struggle to come to terms with the long-term consequences of surviving cancer, such as changes to their body or health problems. A number of people we see have experienced mental health problems in the past – so they are particularly vulnerable.'

Typically, patients are seen for between four and six sessions – although some just need one or two to provide them with the help they need to self-manage their problems.

The support falls under tier three and four of the NICE guidance. Although patients with more complex needs, such as those with suicidal thoughts or severe depression are referred on to core mental health services where there is round-the-clock support available.



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