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Opioid use associated with nonadherence to adjuvant endocrine therapy among breast cancer survivors
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Opioid use appeared significantly associated with nonadherence to adjuvant endocrine therapy among a cohort of breast cancer survivors, according to study results.
Rajesh Balkrishnan, PhD, codirector of the section on population health and prevention research at University of Virginia School of Medicine, and colleagues assessed differences in opioid use across different adjuvant endocrine therapy regimens, the factors associated with opioid use and the impact of opioid use on OS.
The analysis included 10,773 women (mean age, 72.3 years) with incident, primary, hormone-receptor-positive, stage I to stage III breast cancer.
Investigators pooled data on first-time adjuvant endocrine therapy users and fee-for-service Medicare enrollees included in 2006 to 2012 SEER-Medicare datasets.
Researchers followed survivors for at least 2 years from the first date they filled a prescription for adjuvant endocrine therapy.
Results showed women who used aromatase inhibitors only had a similar average treatment effect probability of opioid use as those who used tamoxifen only (56.2% for aromatase inhibitors vs. 55.3% for tamoxifen).
Opioid use appeared significantly associated with nonadherence to adjuvant endocrine therapy, and opioid users demonstrated a significantly higher risk for death (adjusted HR = 1.59; P < .001).
Opioid use also appeared significantly more common among women
Women who switched from aromatase inhibitors to tamoxifen appeared significantly more likely to use opioids than those who used either treatment alone. Opioid use also was higher among those who were younger, single, had more advanced disease or were diagnosed with depression.
HemOnc Today spoke with Balkrishnan about the study results and their implications, as well as the key messages clinicians must convey to their patients about opioid use.
Question: What prompted this research?
Answer: Some of our earlier research focused on adjuvant endocrine therapy use, and we found women who used opioids did not adhere to adjuvant endocrine therapy. This is a very common issue with adjuvant endocrine therapy, a major side effect of which is musculoskeletal spasms. A lot of women who take these medications are required to take them daily, and one of the biggest complaints they have is the muscle spasm pain. Many women cannot even get out of bed because the pain is so bad. Most physicians do not start patients with opioids, but the pain can get so bad that no other drug works other than opioids. The endocrine adjuvant treatment works to prevent subsequent breast cancer in these women and it prolongs survival. When we found that women who use opioids are less likely to adhere to adjuvant treatment, we wanted to explore it further.
Q: What did you find?
A: A lot of women who received prescriptions for opioids did not have a de-escalation plan for issues with abuse and tolerance. When we looked further into the data, we found that women were continuing on opioids for an indefinite amount of time. We found this to be more pronounced among women who lived in rural areas of the United States, as well as minority populations. We additionally confirmed that women who started opioids were more likely to discontinue their endocrine treatment and achieve shorter OS than women who did not take opioids. So, the two major issues we identified were that cancer often is associated with pain — there has not been much work conducted in this area — and that physicians are not de-escalating opioids for women who are breast cancer survivors. I do not know why this is happening. Maybe physicians feel these women have already been through a lot with breast cancer, so they allow them to stay on pain treatment. It also is quite troubling that women who live in rural areas and minority women are more likely to continue on opioids indefinitely, given they most often are seen by primary care physicians and are less likely to receive palliative care or care from oncologists.
Q: Can you describe the clinical implications of your findings?
A: First, we do not ever want to deny these patients pain medication. The pain for some women is really bad and opioids are the only thing that will manage it. However, we want to use this medication safely and effectively so it doesn’t become life-threatening for patients. We understand some of these life-saving treatments do have serious side effects, and that some of the pain cannot be controlled by NSAIDs and may require stronger opioid treatment. However, we need to create a de-escalation plan to ensure these women are not taking opioids indefinitely.
Q: What key messages should clinicians convey to their patients?
A: The best thing to do is to have a very private conversation with patients about the treatments they will be on for the next 10 years. Tell them there potentially will be significant side effects of pain, and there may be the potential for depressive symptoms, as well. It is important that we ensure these women receive the care they need for the depressive symptoms. We also need to ensure that these women stick to their treatment regimen no matter what and, if they do need pain medication, they need to work with a team of physicians — including palliative care physicians — so that their pain can be managed properly.
Q: What are the next steps in research?
A: We are taking the steps to develop an educational intervention for breast cancer survivors in the Appalachian region in the United States, where the opioid epidemic is the worst in the country and outcomes for patients with breast cancer also are worse. This region has the highest likelihood for discontinuation of adjuvant endocrine therapy and also the highest use of opioids. Our hope is to educate this population about their risks and to know how to talk with their physicians about a de-escalation plan.
Q: Is there anything else that you would like to mention?
A: Oncologists need to be cognizant of pain as a common side effect of adjuvant endocrine therapy, which some patients are required to be on continuously for 10 years. This very debilitating pain sometimes needs to be managed with a short course of opioid treatment. It is important, however, that patients be de-escalated from opioids as soon as possible, as prolonged use could lead to nonadherence to adjuvant endocrine therapy and decrease survival. – by Jennifer Southall
Reference:
Tan X, et al. Breast Cancer Res Treat. 2017;doi:10.1007/s10549-017-4348-8.
For more information:
Rajesh Balkrishnan, PhD, can be reached at University of Virginia School of Medicine, 400 Ray C. Hunt Drive, Charlottesville, VA 22902; email: rb9ap@virginia.edu.
Disclosure: Balkrishnan reports no relevant financial disclosures.