Individualized approach to pain management required in metastatic breast cancer
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Most women with metastatic breast cancer require opioids for pain management within a month of diagnosis, according to observational study results published in Scientific Reports.
Nearly half of these women had received an opioid prescription prior to diagnosis of metastatic disease, and this predicted persistent opioid use after diagnosis, results showed.
“Pain requiring opioids is sometimes the first sign that cancer has spread,” Kristina B. Newport, MD, director of palliative care with Penn State Health, told Healio. “The pattern of opioid use we describe, with use prior to metastatic diagnosis predicting persistent use after diagnosis, correlates clinically with patients who have painful metastatic disease.
“The identification of this subgroup of patients is important [because] management of their cancer-related pain may exceed traditional protocols or comfort level of clinicians involved in their care,” Newport added. “These patients may benefit from palliative care consultation or development of specific management protocols to address their pain needs to ensure maximal quality of life while receiving treatment for their metastatic breast cancer.”
Opioid use among individuals with metastatic breast cancer has been understudied, according to the researchers.
“In a previous study, we examined opioid use among [patients with early-stage breast cancer] who had curative surgery and found high prevalence of prolonged opioid use among these patients,” Chan Shen, PhD, associate professor in the department of surgery and chief of the division of outcomes, research and quality at Penn State College of Medicine, told Healio. “That naturally led us to this new study examining the opioid use among [patients with metastatic breast cancer].”
Shen, Newport and colleagues at Penn State Cancer Institute assessed patterns of opioid use among working-age, privately insured women with metastatic breast cancer. They used MarketScan data to identify women diagnosed with metastatic disease between 2006 and 2015.
Their analysis included 24,752 women. Nearly half (46.8%) filled an opioid prescription within 1 year prior to metastatic breast cancer diagnosis, and the majority (81.4%) filled an opioid prescription within 1 year after diagnosis of metastatic disease.
More than half (57.3%) of women received an opioid prescription in the first month after diagnosis; however, that percentage dropped to about 20% in the period from 3 months to 12 months after diagnosis.
The proportion of women who filled opioid prescriptions after diagnosis remained relatively stable during the study period.
In the overall cohort, median daily morphine milligram equivalents (MMEs) and median days’ supply declined over time. Much of the decline occurred in the subgroup of women who had prior prescription opioid use.
“[This finding suggests] that clinicians were becoming more aware of the negative impacts and actively seeking alternative pain management for these patients,” Shen told Healio.
However, among women who received an opioid prescription, the median days’ supply rose significantly during the year after diagnosis of metastatic disease, from 7 in the first month to 19 in the 12th month (P < .001). Median days’ supply increased among both patients without prior opioid use (5 in the first month to 10 in the 12th month; P < .001) and among those with prior opioid use (10 in the first month to 27 in the 12th month; P < .001).
Many patients stopped taking opioids within 2 months after diagnosis. However, opioid prescriptions increased over time among the subgroup of women who had more persistent opioid use (> 90 days).
This finding potentially indicates ongoing cancer-related pain among these women, Shen said.
“This is a subgroup that needs special attention in designing a well-managed pain control regimen,” she said.
Prior opioid use is predictive of higher opioid dosage and prolonged use. Consequently, it is important for clinicians to be aware of patients’ prior opioid use when planning pain management, researchers emphasized.
“Although we are unable to determine why people required opioids prior to metastatic diagnosis, this pattern correlates clinically with people who develop pain from their metastases,” Newport told Healio. “Poorly controlled pain can interfere with function and participation in life-prolonging treatments.
“The intentional assessment and management of pain [among] people with metastatic breast cancer, whether done by oncologists or palliative care clinicians, can improve quality of life and tolerance of life-prolonging treatments,” she added. “Clinicians who are not familiar with managing persistent opioid use [by] patients with metastatic cancer should consult a specialist, such as a palliative care clinician, to aid in safe and effective management of cancer-related pain.”
Several states have adopted legislation to reduce opioid misuse. Much of those efforts have focused on noncancer-related use. The researchers intend to study the impact of state policies on opioid use among individuals with cancer.
The findings of the current study suggest judicious long-term pain management will be necessary for patients diagnosed with metastatic breast cancer, researchers concluded.
“Chronic pain is highly prevalent among [patients with advanced cancer], and the cause of such pain varies substantially among patients,” Shen said. “It is important to adopt an individualized approach and involve the patients in the medical decision-making.”
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