Urban-rural Disparities in Suicide Mortality Among Head and Neck Cancer Patients: A Population-based Analysis

Introduction: Patients with cancer have elevated suicide risk, but differences by cancer type and rural vs urban residence are not well characterized. Patients with head and neck (H&N) cancer may be particularly vulnerable due to functional impairment, visible disfigurement, and high symptom burden. We used national mortality data to quantify suicide among H&N cancer patients and examine disparities by urbanization status and sex.

Methods: We performed a cross-sectional analysis of CDC WONDER Multiple Cause-of-Death data for U.S. adults, 1999-2020. Suicide as the underlying cause of death was defined by ICD-10 codes X60-X84 and Y87.0. H&N cancers were identified using ICD-10 C00–C14 and C30–C32 as underlying or contributing causes. Suicide proportions and stratified proportions were calculated using the 2013 NCHS urbanization category, sex, calendar period, and Census region. Odds ratios (OR), p-values, and 95% confidence intervals were estimated using binomial logistic regression.

Results: H&N cancer patients exhibited significantly higher suicide odds compared to patients with other malignancies (0.13% vs 0.05%; OR 2.6, p< 0.001). Within the H&N cohort, suicide odds increased progressively with greater rurality, peaking in noncore rural vs large central metro counties (OR 1.96, p< 0.001). This trend was predominantly male-driven, with rural men showing higher suicide odds than metropolitan males (OR 1.6, p< 0.001). Males also demonstrated a threefold higher risk than females (OR 3.1, p< 0.01) in large central metro areas. Temporally, rural-urban differences became pronounced only post-2009 (p=0.002) and particularly in the Midwest and West. No significant differences were observed between economic recession and non-recession years.

Conclusions: Suicide was substantially more common in H&N cancer than in other malignancies, with the highest burden in rural communities and among men. H&N patients in rural settings should be considered a priority population for proactive suicide prevention efforts, including routine distress screening and timely mental health referral to mitigate this widening gap.