Appl Clin Inform 2024; 15(02): 404-413
DOI: 10.1055/s-0044-1787006
Special Section on Patient-Reported Outcomes and Informatics

Suicide Risk Screening for Head and Neck Cancer Patients: An Implementation Study

Bhargav Kansara
1   Department of Oncological Sciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, United States
Ameer Basta
1   Department of Oncological Sciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, United States
Marian Mikhael
1   Department of Oncological Sciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, United States
Randa Perkins
2   Department of Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, Florida, United States
3   Department of Clinical Informatics, Center for Digital Health, Moffitt Cancer Center, Tampa, Florida, United States
Phillip Reisman
3   Department of Clinical Informatics, Center for Digital Health, Moffitt Cancer Center, Tampa, Florida, United States
Julie Hallanger-Johnson
4   Mayo Clinic College of Medicine and Science, Division of Endocrinology, Metabolism, Diabetes, and Nutrition, Rochester, Minnesota, United States
Dana E. Rollison
5   Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida, United States
Oliver T. Nguyen
6   Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida, United States
Sean Powell
7   Department of Social Work, Moffitt Cancer Center, Tampa, Florida, United States
Scott M. Gilbert
8   Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, United States
Kea Turner
6   Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida, United States
9   Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, United States
› Author Affiliations
Funding This research was supported in part by the Participant Research, Interventions, and Measurements Core at the Moffitt Cancer Center, a National Cancer Institute-designated Comprehensive Cancer Center (P30-CA076292).


Objectives There is limited research on suicide risk screening (SRS) among head and neck cancer (HNC) patients, a population at increased risk for suicide. To address this gap, this single-site mixed methods study assessed oncology professionals' perspectives about the feasibility, acceptability, and appropriateness of an electronic SRS program that was implemented as a part of routine care for HNC patients.

Methods Staff who assisted with SRS implementation completed (e.g., nurses, medical assistants, advanced practice providers, physicians, social workers) a one-time survey (N = 29) and interview (N = 25). Quantitative outcomes were assessed using previously validated feasibility, acceptability, and appropriateness measures. Additional qualitative data were collected to provide context for interpreting the scores.

Results Nurses and medical assistants, who were directly responsible for implementing SRS, reported low feasibility, acceptability, and appropriateness, compared with other team members (e.g., physicians, social workers, advanced practice providers). Team members identified potential improvements needed to optimize SRS, such as hiring additional staff, improving staff training, providing different modalities for screening completion among individuals with disabilities, and revising the patient-reported outcomes to improve suicide risk prediction.

Conclusion Staff perspectives about implementing SRS as a part of routine cancer care for HNC patients varied widely. Before screening can be implemented on a larger scale for HNC and other cancer patients, additional implementation strategies may be needed that optimize workflow and reduce staff burden, such as staff training, multiple modalities for completion, and refined tools for identifying which patients are at greatest risk for suicide.

Availability of the Data

To protect the privacy of the individuals that participated in this study, the individual-level data underlying this article cannot be shared. Summary-level data may be requested.

Author Contributions

B.K.: Conceptualization; Writing—original draft; Writing—review & editing; Methodology; A.B.: Writing—review & editing; M.M.: Writing—review & editing; R.P.: Writing—review & editing; P.R.: Writing—review & editing; J.H.J.: Writing—review & editing; D.E.R.: Writing—review & editing; O.T.N.: Writing—review & editing; S.P.: Writing—review & editing; S.M.G.: Writing—review & editing; K.T.: Conceptualization; Methodology; Project administration.

Protection of Human and Animal Subjects

Moffitt Cancer Center Institutional Review Board of Record, Advarra, reviewed the study protocol and determined the study to be exempt.

Supplementary Material

Publication History

Received: 12 January 2024

Accepted: 27 March 2024

Article published online:
22 May 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

  • References

  • 1 Fang F, Fall K, Mittleman MA. et al. Suicide and cardiovascular death after a cancer diagnosis. N Engl J Med 2012; 366 (14) 1310-1318
  • 2 Henson KE, Brock R, Charnock J, Wickramasinghe B, Will O, Pitman A. Risk of suicide after cancer diagnosis in England. JAMA Psychiatry 2019; 76 (01) 51-60
  • 3 Misono S, Weiss NS, Fann JR, Redman M, Yueh B. Incidence of suicide in persons with cancer. J Clin Oncol 2008; 26 (29) 4731-4738
  • 4 Ravaioli A, Crocetti E, Mancini S. et al. Suicide death among cancer patients: new data from northern Italy, systematic review of the last 22 years and meta-analysis. Eur J Cancer 2020; 125: 104-113
  • 5 Zaorsky NG, Zhang Y, Tuanquin L, Bluethmann SM, Park HS, Chinchilli VM. Suicide among cancer patients. Nat Commun 2019; 10 (01) 207
  • 6 Osazuwa-Peters N, Simpson MC, Zhao L. et al. Suicide risk among cancer survivors: head and neck versus other cancers. Cancer 2018; 124 (20) 4072-4079
  • 7 Kam D, Salib A, Gorgy G. et al. Incidence of suicide in patients with head and neck cancer. JAMA Otolaryngol Head Neck Surg 2015; 141 (12) 1075-1081
  • 8 Sung H, Ferlay J, Siegel RL. et al. Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021; 71 (03) 209-249
  • 9 Echeverria I, Cotaina M, Jovani A, Mora R, Haro G, Benito A. Proposal for the inclusion of tobacco use in suicide risk scales: results of a meta-analysis. Int J Environ Res Public Health 2021; 18 (11) 6103
  • 10 Isaacs JY, Smith MM, Sherry SB, Seno M, Moore ML, Stewart SH. Alcohol use and death by suicide: a meta-analysis of 33 studies. Suicide Life Threat Behav 2022; 52 (04) 600-614
  • 11 Chua KS, Reddy SK, Lee MC, Patt RB. Pain and loss of function in head and neck cancer survivors. J Pain Symptom Manage 1999; 18 (03) 193-202
  • 12 Chang DC, Chen AW, Lo YS, Chuang YC, Chen MK. Factors associated with suicidal ideation risk in head and neck cancer: a longitudinal study. Laryngoscope 2019; 129 (11) 2491-2495
  • 13 Massa ST, Osazuwa-Peters N, Adjei Boakye E, Walker RJ, Ward GM. Comparison of the financial burden of survivors of head and neck cancer with other cancer survivors. JAMA Otolaryngol Head Neck Surg 2019; 145 (03) 239-249
  • 14 Gardner W, Klima J, Chisolm D. et al. Screening, triage, and referral of patients who report suicidal thought during a primary care visit. Pediatrics 2010; 125 (05) 945-952
  • 15 Etter DJ, McCord A, Ouyang F. et al. Suicide screening in primary care: use of an electronic screener to assess suicidality and improve provider follow-up for adolescents. J Adolesc Health 2018; 62 (02) 191-197
  • 16 Davis M, Rio V, Farley AM, Bush ML, Beidas RS, Young JF. Identifying adolescent suicide risk via depression screening in pediatric primary care: an electronic health record review. Psychiatr Serv 2021; 72 (02) 163-168
  • 17 Fein JA, Pailler ME, Barg FK. et al. Feasibility and effects of a web-based adolescent psychiatric assessment administered by clinical staff in the pediatric emergency department. Arch Pediatr Adolesc Med 2010; 164 (12) 1112-1117
  • 18 Wintersteen MB. Standardized screening for suicidal adolescents in primary care. Pediatrics 2010; 125 (05) 938-944
  • 19 Gascon B, Leung Y, Espin-Garcia O, Rodin G, Chu D, Li M. Suicide risk screening and suicide prevention in patients with cancer. JNCI Cancer Spectr 2021; 5 (04) pkab057
  • 20 Stover AM, Kurtman R, Walker Bissram J. et al. Stakeholder perceptions of key aspects of high quality cancer care to assess patient-reported outcome measures: a systematic review. Cancers 2021; 13 (14) 3628
  • 21 Stover AM, Tompkins Stricker C, Hammelef K. et al. Using stakeholder engagement to overcome barriers to implementing patient-reported outcomes (PROs) in cancer care delivery: approaches from 3 prospective studies. Med Care 2019; 57 (1, Suppl 5 Suppl 1): S92-S99
  • 22 Basch E, Deal AM, Dueck AC. et al. Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. JAMA 2017; 318 (02) 197-198
  • 23 Basch E, Deal AM, Kris MG. et al. Symptom monitoring with patient-reported outcomes during routine cancer treatment: a randomized controlled trial. J Clin Oncol 2016; 34 (06) 557-565
  • 24 Denis F, Basch E, Septans AL. et al. Two-year survival comparing web-based symptom monitoring vs routine surveillance following treatment for lung cancer. JAMA 2019; 321 (03) 306-307
  • 25 Donovan KA, Jacobsen PB. Progress in the implementation of NCCN guidelines for distress management by member institutions. J Natl Compr Canc Netw 2013; 11 (02) 223-226
  • 26 Donovan KA, Deshields TL, Corbett C, Riba MB. Update on the implementation of NCCN guidelines for distress management by NCCN member institutions. J Natl Compr Canc Netw 2019; 17 (10) 1251-1256
  • 27 Jacobsen PB, Ransom S. Implementation of NCCN distress management guidelines by member institutions. J Natl Compr Canc Netw 2007; 5 (01) 99-103
  • 28 Jacobsen PB, Norton WE. The role of implementation science in improving distress assessment and management in oncology: a commentary on “Screening for psychosocial distress among patients with cancer: implications for clinical practice, healthcare policy, and dissemination to enhance cancer survivorship”. Transl Behav Med 2019; 9 (02) 292-295
  • 29 Palinkas LA, Aarons GA, Horwitz S, Chamberlain P, Hurlburt M, Landsverk J. Mixed method designs in implementation research. Adm Policy Ment Health 2011; 38 (01) 44-53
  • 30 Kim H, Sefcik JS, Bradway C. Characteristics of qualitative descriptive studies: a systematic review. Res Nurs Health 2017; 40 (01) 23-42
  • 31 Johnstone PAS, Lee J, Zhou JM. et al. A modified Edmonton Symptom Assessment Scale for symptom clusters in radiation oncology patients. Cancer Med 2017; 6 (09) 2034-2041
  • 32 Johnstone PAS, Bulls HW, Zhou JM. et al. Congruence of multiple patient-related outcomes within a single day. Support Care Cancer 2019; 27 (03) 867-872
  • 33 Bulls HW, Chang PH, Brownstein NC. et al. Patient-reported symptom burden in routine oncology care: examining racial and ethnic disparities. Cancer Rep (Hoboken) 2022; 5 (03) e1478
  • 34 Turner K, Brownstein NC, Thompson Z. et al. Longitudinal patient-reported outcomes and survival among early-stage non-small cell lung cancer patients receiving stereotactic body radiotherapy. Radiother Oncol 2022; 167: 116-121
  • 35 Noel CW, Forner D, Chepeha DB. et al. The Edmonton Symptom Assessment system: a narrative review of a standardized symptom assessment tool in head and neck oncology. Oral Oncol 2021; 123: 105595
  • 36 Nekolaichuk C, Watanabe S, Beaumont C. The Edmonton Symptom Assessment system: a 15-year retrospective review of validation studies (1991–2006). Palliat Med 2008; 22 (02) 111-122
  • 37 Hoffman BM, Zevon MA, D'Arrigo MC, Cecchini TB. Screening for distress in cancer patients: the NCCN rapid-screening measure. Psychooncology 2004; 13 (11) 792-799
  • 38 Weiner BJ, Lewis CC, Stanick C. et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci 2017; 12 (01) 108
  • 39 Proctor E, Silmere H, Raghavan R. et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health 2011; 38 (02) 65-76
  • 40 Wood KC, Pergolotti M, Marshall T. et al. Usability, acceptability, and implementation strategies for the Exercise in Cancer Evaluation and Decision Support (EXCEEDS) algorithm: a Delphi study. Support Care Cancer 2022; 30 (09) 7407-7418
  • 41 Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009; 4: 50
  • 42 Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods 2006; 5 (01) 80-92
  • 43 Hamilton AB, Finley EP. Qualitative methods in implementation research: an introduction. Psychiatry Res 2019; 280: 112516
  • 44 Guest G, Namey E, Chen M. A simple method to assess and report thematic saturation in qualitative research. PLoS One 2020; 15 (05) e0232076
  • 45 Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007; 19 (06) 349-357
  • 46 Nguyen H, Butow P, Dhillon H, Sundaresan P. A review of the barriers to using patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs) in routine cancer care. J Med Radiat Sci 2021; 68 (02) 186-195
  • 47 Foster A, Croot L, Brazier J, Harris J, O'Cathain A. The facilitators and barriers to implementing patient reported outcome measures in organisations delivering health related services: a systematic review of reviews. J Patient Rep Outcomes 2018; 2: 46
  • 48 Glenwright BG, Simmich J, Cottrell M. et al. Facilitators and barriers to implementing electronic patient-reported outcome and experience measures in a health care setting: a systematic review. J Patient Rep Outcomes 2023; 7 (01) 13
  • 49 Antunes B, Harding R, Higginson IJ. EUROIMPACT. Implementing patient-reported outcome measures in palliative care clinical practice: a systematic review of facilitators and barriers. Palliat Med 2014; 28 (02) 158-175
  • 50 Santana MJ, Haverman L, Absolom K. et al. Training clinicians in how to use patient-reported outcome measures in routine clinical practice. Qual Life Res 2015; 24 (07) 1707-1718
  • 51 Skovlund PC, Ravn S, Seibaek L, Thaysen HV, Lomborg K, Nielsen BK. The development of PROmunication: a training-tool for clinicians using patient-reported outcomes to promote patient-centred communication in clinical cancer settings. J Patient Rep Outcomes 2020; 4 (01) 10
  • 52 Ballengee LA, Rushton S, Lewinski AA. et al. Effectiveness of quality improvement coaching on process outcomes in health care settings: a systematic review. J Gen Intern Med 2022; 37 (04) 885-899
  • 53 Gilkey MB, Heisler-MacKinnon J, Boynton MH, Calo WA, Moss JL, Brewer NT. Impact of brief quality improvement coaching on adolescent HPV vaccination coverage: a pragmatic cluster randomized trial. Cancer Epidemiol Biomarkers Prev 2023; 32 (07) 957-962
  • 54 Bennett AV, Dueck AC, Mitchell SA. et al; National Cancer Institute PRO-CTCAE Study Group. Mode equivalence and acceptability of tablet computer-, interactive voice response system-, and paper-based administration of the U.S. National Cancer Institute's Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). Health Qual Life Outcomes 2016; 14: 24
  • 55 Owen-Smith A, Mayhew M, Leo MC. et al. Automating collection of pain-related patient-reported outcomes to enhance clinical care and research. J Gen Intern Med 2018; 33 (Suppl. 01) 31-37
  • 56 Barak-Corren Y, Castro VM, Nock MK. et al. Validation of an electronic health record-based suicide risk prediction modeling approach across multiple health care systems. JAMA Netw Open 2020; 3 (03) e201262
  • 57 Walsh CG, Johnson KB, Ripperger M. et al. Prospective validation of an electronic health record-based, real-time suicide risk model. JAMA Netw Open 2021; 4 (03) e211428
  • 58 Nock MK, Millner AJ, Ross EL. et al. Prediction of suicide attempts using clinician assessment, patient self-report, and electronic health records. JAMA Netw Open 2022; 5 (01) e2144373
  • 59 Haroz EE, Kitchen C, Nestadt PS, Wilcox HC, DeVylder JE, Kharrazi H. Comparing the predictive value of screening to the use of electronic health record data for detecting future suicidal thoughts and behavior in an urban pediatric emergency department: a preliminary analysis. Suicide Life Threat Behav 2021; 51 (06) 1189-1202
  • 60 Walker RL, Shortreed SM, Ziebell RA. et al. Evaluation of electronic health record-based suicide risk prediction models on contemporary data. Appl Clin Inform 2021; 12 (04) 778-787
  • 61 Henry M, Rosberger Z, Bertrand L. et al. Prevalence and risk factors of suicidal ideation among patients with head and neck cancer: longitudinal study. Otolaryngol Head Neck Surg 2018; 159 (05) 843-852
  • 62 Bryan CJ, Allen MH, Thomsen CJ. et al. Improving suicide risk screening to identify the highest risk patients: results from the PRImary Care Screening Methods (PRISM) study. Ann Fam Med 2021; 19 (06) 492-498