Medication Use Signals Unmet Psychological Needs in Older Breast Cancer Survivors

Crystal Denlinger, MD

Crystal Denlinger, MD

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 study published in the Journal of the National Comprehensive Cancer Network.

“Women over 65 represent the fastest growing segment of breast cancer survivors. The fact that so many of them need medications for anxiety, depression, and distress even after active cancer care highlights the fact that we know so little about the specific needs of these patients.” said principal investigator, Ari Meguerditchian, MD, MSc, FRCS, in a statement. Meguerditchian is an assistant professor in the Departments of Surgery and Oncology, and member of the clinical and health informatics research group at McGill University,

The study looked at more than 19,500 women aged ≥65 years with incident, nonmetastatic breast cancer in Quebec, Canada between January 1998 and March 2011. Researchers analyzed the use of anti-anxiety medications, antidepressants, and antipsychotics, as well as opioids at baseline, through treatment, and into the first year of survivorship.

While anti-anxiety medications 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% used antipsychotics, which was a 7- and 4.5-fold respective increase from the precancer baseline. The use of opioids and antipsychotics decreased from those levels when patients transitioned into survivorship care to 9.6% and 5.6%, respectively.

However, the anxiolytic use only decreased from 50.6% during active care to just 44.4% in survivorship. For antidepressants, there was just a 0.1% decrease, from 22.4% in active care to 22.3% in survivorship.

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

Crystal Denlinger, MD, chief of the Division of Gastrointestinal Medical Oncology at Fox Chase Cancer Center, explained in a statement that the increased use of medications during treatment is, “not surprising due to the current treatment of nonmetastatic breast cancer.” The notable dropoff 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 anti-anxiety medications 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.”

“Our findings raise important questions about the lasting psychological impact of cancer, such as uncertainty of recurrence, family hardships, etc. Are we supporting our older patients as they move to survivorship? How can we best address their needs?” asked Meguerditchian.

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. They stressed the importance of “early identification of distress and pain” and prompt 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. The authors pointed to studies, for example, showing that “cognitive behavior therapy has positive effects on both reducing pain and distress in patients with breast cancer.”

Denlinger, who is not an author on the study, 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, et al. 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(11):1412-1419.