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August 29, 2019
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Depression, anxiety increase risk for opioid use, death among breast cancer survivors

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Rajesh Balkrishnan
Rajesh Balkrishnan

Mental health comorbidities such as depression and anxiety increased risks for opioid use and mortality among older breast cancer survivors, according to study results published in Journal of Oncology Practice.

“Studies have found that many breast cancer survivors stop taking their first-line adjuvant hormone treatments,” Rajesh Balkrishnan, PhD, co-program director of population health and prevention sciences and director of the Cancer Control Core at University of Virginia Cancer Center, said in an interview with HemOnc Today. “We were trying to understand the reasons this was happening. One of the things that came up was that many of these medications are associated with musculoskeletal side effects. So, there needs to be a concurrent pain management treatment for many of the women who are on these medications.”

Balkrishnan said although nonhabit-forming medications such as Advil or Motrin achieve adequate pain relief for some women, others continue to experience debilitating pain.

“Many of these women need to be put on short courses of opioids just to manage the pain, and then a plan has to be put in place to bring the women off the opioids,” he said.

However, Balkrishnan and his colleagues noticed that many of these women were continuing to refill opioid prescriptions for extended periods of time. The researchers decided to further assess the potential factors contributing to this behavior.

“We started looking at this in more detail, and we started identifying the characteristics of these women a bit better,” he said. 

‘A complicated phenomenon’

In the retrospective cohort study, Balkrishnan and colleagues assessed SEER-Medicare data sets spanning 2006 to 2012 and followed 10,452 breast cancer survivors for a minimum of 2 years from the first date they filled a prescription for adjuvant endocrine therapy. The study population consisted of adult women with primary, hormone receptor-positive stage I to stage III breast cancer. The researchers evaluated opioid use after commencement of adjuvant endocrine therapy among survivors with diagnosed mental health comorbidities, the most common of which included depression (n = 554) and anxiety (n = 246). They also assessed survival at the end of the study interval.

Survivors with mental health comorbidities (n = 739) appeared more likely than those without mental health comorbidities (n = 9,713) to have been diagnosed with breast cancer at age 64 years or younger (30.7% vs. 8.7%) and to be white (88% vs. 84.2%) and single (69.6% vs. 56.5%). A majority of patients with mental health comorbidities were eligible for both Medicare and Medicaid (52.2%), had a pre-diagnosis Charlson comorbidity index of 0 (51.1%), experienced pain-related conditions (70%) and had stage I cancer (58.3%).

To balance comparison groups and minimize potential bias due to confounding, researchers created a propensity score-matched sample (n = 1,474). Among that sample, conditional logistic regression revealed women with mental health comorbidities were 33% more likely to use opioids than those with no such comorbidities (OR = 1.33; 95% CI, 1.06-1.68). Moreover, Cox proportional hazards regression showed those with mental health comorbidities had a significantly increased risk for death (HR = 1.49; 95% CI, 1.02-2.18).

 “A lot of these women seem to be having mental health conditions like anxiety and depression, which I think is fueling this type of behavior,” Balkrishnan said. “This is a fairly complicated phenomenon where there are many things going on at the same time.”

Many of the women who continued to refill opioid prescriptions also lived in rural areas with limited access to high-quality cancer care, Balkrishnan added.

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‘Not a death sentence’

As many as 40% of patients with breast cancer have a mental health comorbidity, and previous studies have shown a strong association between mental health and use of opioids, according to researchers.

The researchers acknowledged several limitations to their study, including a lack of knowledge about the indications for the opioids used, the level of pain evaluations and opioid strength or dosage.

According to Balkrishnan, these findings suggest a need for clinicians to discuss issues of pain management with breast cancer patients, and to address depression or anxiety that may arise from a cancer diagnosis.

Balkrishnan said many of the women who continued to fill opioid prescriptions lived in rural areas with limited access to high-quality cancer care.

“Clinicians treating these patients need to realize that there needs to be a plan in place, and it needs to be emphasized that this is not a death sentence, that with treatment, many women go on to live into their eighties,” he told HemOnc Today. “We don’t want these women to beat cancer only to die of an opioid overdose. What needs to be said is that this is going to be difficult, but they shouldn’t worry; we’re going to fight it together.” by Jennifer Byrne

For more information:

Rajesh Balkrishnan, PhD, can be reached at University of Virginia School of Medicine, PO Box 800765, Charlottesville, VA 22908; email: rb9ap@virginia.edu.

Disclosures: Balkrishnan reports a consultant/advisory role with Merck. No other study authors report relevant financial disclosures.