A study presented this week at the virtual meeting of the San Antonio Breast Cancer Symposium (SABCS) found that people who underwent mastectomy and breast reconstruction were at increased risk of developing dependence on pain and sedative medication.
The study showed that 13.1 percent of patients who were not prior opioid users became new persistent opioid users after surgery. Researchers found 6.6 percent of patients who were not prior sedative-hypnotic users became persistent users after surgery.
“It’s striking how many patients this is an issue for. It’s more than maybe we would have thought prior to doing the study,” said the lead author, Jacob Cogan, MD, a fellow in hematology-oncology at NewYork-Presbyterian Columbia University Irving Medical Center in New York City.
The study on the risk for drug dependence grew out of concerns regarding the epidemic of opioid medication misuse across the country over the past decade. Research shows that even short-term use of opioids for pain relief can lead to long-term dependence.
“As the opioid epidemic in the U.S. continues, the rate of opioid dependence in the cancer population continues to increase as well,” said Dr. Cogan.
According to previous research, about 10 percent of patients become persistent opioid users following breast cancer surgery, Cogan said. But dependence rates after mastectomy and reconstructive surgery have been unknown. In addition to opioid painkillers, women undergoing mastectomy and breast reconstructive surgery may also receive sedative medications to alleviate anxiety or insomnia, and those drugs can also lead to dependence.
The study featured an analysis of data from the MarketScan healthcare claims database of women who underwent mastectomy and breast reconstruction between 2008 and 2017. The researchers looked at prescriptions for opioids and sedative-hypnotic medications in the preoperative period, perioperative period (31 to 90 days after surgery) and postoperative period (90 to 365 days after surgery). They further identified women who were not prior opioid users and those who were not prior users of sedative-hypnotics.
In addition to the risk of dependence, analysis of the data showed that the risk of becoming a persistent user of a controlled substance was much higher in women under age 60, those with a breast cancer diagnosis (in contrast to women who had prophylactic mastectomy), and patients treated with chemotherapy. The higher the number of risk factors, the higher the risk of developing persistent drug use, the study found.
While both opioids and sedative-hypnotics are important tools to help patients for symptom relief through surgery and recovery, the study points to the need to be aware of risk factors for developing dependence.
Moreover, the study suggests that physicians need to address ways to prevent drug dependence. For example, Cogan said, research should address the idea of having patients ask for a prescription if needed rather than physicians automatically sending patients home with a prescription. At follow-up doctor visits, patients should be asked if they have discontinued use of the medications and, if so, if they have properly disposed of the drugs, he added.
“The issue is once they don’t [need the medications], don’t just leave them there at their home,” Cogan said. “Studies show that’s when people get addicted to these medications.”
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Pregnancy After Breast Cancer: Hard but Not Impossible
Another study presented at the conference found that premenopausal survivors of breast cancer are less likely to get pregnant, but typically have healthy babies when the do. The study is important because women now typically have children much later in life, and it has become more common for older-age maternity patients to have a history of breast cancer.
The study was an analysis of previous research on pregnancy after breast cancer. Researchers compiled data from 39 studies that identified women who had been pregnant after a breast cancer diagnosis. They evaluated the outcomes of pregnancies, including both fetal and obstetrical outcomes.
Compared with women in the general population, survivors of breast cancer had a 60 percent reduced chance of having a pregnancy — although that number also includes women who may not have tried to become pregnant following breast cancer treatment.
A sub-analysis of studies that reported the number of women trying to conceive after breast cancer found that about half were successful, said the study’s corresponding author, Matteo Lambertini, MD, PhD, an adjunct professor in medical oncology at the University of Genova–IRCCS Policlinico San Martino Hospital in Genoa, Italy.
Some studies also found that some patients who were not trying to conceive after breast cancer treatment did become pregnant.
Researchers found that compared with women in the general population, breast cancer survivors had a 50 percent higher risk of having a baby with low birth weight, a 16 percent higher risk of having a baby that was small for gestational age, a 45 percent higher risk of preterm labor, and a 14 percent higher risk of a cesarean section.
There were no increased risks of congenital defects or other pregnancy complications in breast cancer survivors, however. Moreover, pregnancy did not lead to poor outcomes for maternal health. Women who got pregnant had a 48 percent reduced risk of death and a 26 percent reduced risk of disease recurrence compared with breast cancer survivors who did not become pregnant.
The study shows that pregnant breast cancer survivors should be closely monitored for complications, but that pregnancy should not be discouraged. Moreover, breast cancer survivors who do not wish to become pregnant may need contraceptives counseling.
“These findings are of paramount importance to raise awareness of the need for a deeper consideration of patients’ pregnancy desire as a crucial component of their survivorship care plan,” Dr. Lambertini said. “This starts with offering oncofertility counseling to all newly diagnosed young breast cancer patients.”
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Circulating DNA Tests Helpful in Monitoring Breast Cancer
Early detection of circulating tumor cells, called CTCs or circulating DNA, in women with metastatic breast cancer can help predict treatment response, according to a study from German researchers.
The study looked at the use of CTC tests, which are simple blood tests, to monitor patients’ response to treatment. CTC tests can provide more rapid insight into possible relapse compared with the traditional type of monitoring consisting of imaging tests, noted the lead author of the study, Wolgang Janni, MD, PhD, a professor and the director of the women’s clinic at Ulm University Hospital in Ulm, Germany.
The meta-analysis included 4,097 patients with metastatic breast cancer who had follow-up CTC tests early in the course of treatment. The study found median survival rates were highest in women who had negative CTC tests at the start of treatment and 29 days later, while rates were lowest for those who had an initial positive CTC test and remained positive at 29 days. The tests predicted outcomes reliably for all breast cancer subtypes.
CTC test data can help a physician know if an initial treatment should be discontinued. The advantage of the test is that it can be performed much earlier after treatment begins. “It has to be early enough to provide an added value compared with imaging,” said Dr. Janni.
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