Breast Cancer Survivors Remain Underserved for Psychological Side Effects

Patients with breast cancer aged 65 and older often use psychotropic and opioid medications during active treatment and into the first year of their survivorship, according to a new McGill University study published in the Journal of the National Comprehensive Cancer Network.

This trend highlights the fact that there are unmet needs in this population of patients, especially when it comes to psychosocial issues. Older survivors of breast cancer need a multidimensional approach to distress and anxiety, which includes comprehensive psychological interventions.

The study, “Psychotropic and Opioid Medication Use in Older Patients with Breast Cancer across the Care Trajectory: A Population-Based Cohort Study,” looked at more than 19,500 women,65 years and older with incident, non-metastatic breast cancer in Quebec, Canada between January 1998 and March 2011. Researchers analyzed the use of anxiolytics, antidepressants and antipsychotics, as well as opioids from the precancer baseline, through treatment and into the first year of survivorship.

While anxiolytics and antidepressants were the most prescribed drugs, there was an increase from baseline to active care in the use of opioids and antipsychotics. Once in active treatment, 25 percent of patients used opioids and 16.2 percent used antipsychotics, which was a 7-fold and 4.5-fold respective increase from the precancer baseline.

The use of opioids and antipsychotics decreased into survivorship care from 25 percent and 16.2 percent respectively to 9.6 percent and 5.6 percent. However, the decrease of anxiolytics was from 50.6 percent during active care to just 44.4 percent in survivorship. For antidepressants, there was just a 0.1 percent decrease, from 22.4 percent in active care to 22.3 percent in survivorship.

Of all the patients, only 31.6 percent did not use any psychotropic medications throughout the entirety of the care trajectory.

Crystal Delinger, M.D., chief of Division of Gastrointestinal Medical Oncology at Fox Chase Cancer Center explained that the increased use of medications during treatment is “not surprising due to the current treatment of nonmetastatic breast cancer.” The notable drop-off in antipsychotic and opioid use in the first year of survivorship can be explained by a decrease of physical side effects once treatment is completed.

Meanwhile, the psychological aspects such as distress and anxiety, can have an extended effect. This lasting psychological impact of cancer leaves providers with questions on how to best address the needs of their older patients.

The authors on the study noted a number of reasons for the continued use of anxiolytics and antidepressants into breast cancer survivorship. Distress during this period can be caused by “fear of cancer recurrence, chronic or latent treatment-related side effects, or financial burden.”

Specific types of psychotropic and opioid drugs can be potentially inappropriate for older adults, according to the authors on the study, because of increased risks for serious adverse events. The authors explained the importance of “early identification of distress and pain” with “timely intervention.”

Psychotherapy could be considered a viable option for intervention, rather than pharmacotherapy. For instance, there are prevention strategies which can improve coping and help patients to manage distress and pain. Studies have shown that “cognitive behavior therapy has positive effects on both reducing pain and distress in patients with breast cancer.”

Delinger expressed concern about the trend toward continued medication through survivorship and said it should be evaluated further. “Understanding the reasons for use of these medications and development of better interventions to address underlying causes is critical to ensuring the best outcomes for this, and potentially other, patient populations.”

Reference Syrowatka A, Chang SL, Tamblyn R, Mayo NE, Meguerditchian AN. Psychotropic and Opioid Medication Use in Older Patients With Breast Cancer Across the Care Trajectory: A Population-Based Cohort Study. J Natl Compr Canc Netw. 2016(14):1412-1419.