Managing suicidal ideation in a breast cancer cohort seeking reconstructive surgery

Emotional and social adaptation is a central challenge for women with recently diagnosed breast cancer [1]. Prevalence rates for anxiety and depressive disorders among a heterogeneous sample of cancer patients are estimated to range from 10 to 40% [2,3], and women with newly diagnosed breast cancer demonstrate comparable rates of affective distress [4]. As a result, breast reconstruction outcome studies routinely assess psychological variables and their influence on various patient-specific outcomes such as aesthetic satisfaction and functional status. While these studies typically include measures of preoperative depression and anxiety as possible predictors of clinical outcomes, relatively little attention has been paid to the identification of suicidal ideation (SI) in this cohort. This may seem surprising given evidence that depression is highly prevalent among cancer patients and, when increasingly severe, presents a primary risk for SI and intention [5]. While numerous studies describe the incidence of suicide among cancer patients in general [6], and women with breast cancer more specifically [7], there is sparse information on the prevalence of suicidal ideation among these populations. The assessment of SI in breast cancer patients presenting for reconstruction is in line with the American College of Surgeons (ACS) Commission on Cancer guidelines for distress screening of all cancer patients by 2015 [8]. We examined the prevalence of preoperative anxiety and depression among women enrolled in an ongoing prospective study of post-mastectomy breast reconstruction procedure outcomes. The prevalence of moderate-to-severe SI challenged the study team to devise an identification and response system to intervene with potential at-risk patients and triage them to appropriate mental health attention. We describe this system and propose its consideration for future surgical outcome studies where depression and SI are of reasonable concern.