Elderly women battling breast cancer who have anxiety, depression, or other mental health conditions are more likely to use opioids and more likely to die, a new study led by the University of Virginia School of Medicine suggests.

The findings should encourage doctors to better manage mental health in patients with breast cancer and spur care providers to consider alternative pain management such as physical therapy, massage, and acupuncture, the researchers say.

“The complex relationship among breast cancer, mental health problems, and the use of opioids is not well understood, and the results of this study provide clinicians the evidence they need to make optimal patient treatment-related decisions,” said lead researcher Rajesh Balkrishnan, PhD, of the Department of Public Health Sciences and the UVA Cancer Center. “Our findings suggest that patients with breast cancer with mental health conditions have higher opioid use and reduced survival. These results highlight the need for healthcare providers to evaluate treatment goals and assess whether better concurrent management of breast cancer and mental health conditions is required.”

Breast cancer and opioids

Breast cancer kills more than 40,000 people in the United States each year, and patients often suffer from anxiety and depression. Research suggests that about 40% of patients with breast cancer have some type of mental health diagnosis.

Balkrishnan and his team set out to shed light on the relationship among mental health, opioid use, and breast cancer outcomes. To do that, they reviewed more than 10,000 breast cancer cases recorded in the national SEER cancer database, which contains detailed (but depersonalized) information on care provided to Medicare beneficiaries with cancer. These cases consisted of women aged 65 years and older who were diagnosed with stage I, II, or III breast cancer between January 1, 2006, and December 31, 2012. All received adjuvant endocrine therapy as treatment.

The researchers sorted the cases into two groups: women with mental health diagnoses and those without. They found that those with mental health diagnoses had higher opioid use and lower survival rates.

“Opioid use is higher in the women with breast cancer who suffer from mental health comorbidities and remains a significant problem,” the researchers write in a new paper outlining their findings. “In addition, mental health comorbidities also contribute to reduced survival in these women. A need exists for collaborative care in the management of mental health comorbidities in women with breast cancer, which could improve symptoms, adherence to treatment, and recovery from these mental conditions. Mental health treatments also are recommended to be offered in primary care, which not only would be convenient for patients but also would reduce the stigma associated with treatments for mental health comorbidities and improve the patient-provider relationship.”

The researchers, including UVA palliative care expert Leslie Blackhall, MD, recommend that doctors and other care providers consider “complementary forms of treatment for pain,” such as physical therapy, cognitive behavioral therapy, acupuncture, acupressure, and massage.

Findings published

The researchers have published their findings in the Journal of Oncology Practice. In addition to Balkrishnan and Blackhall, the study’s authors were Raj Desai of the University of Florida; Fabian Camacho of the UVA School of Medicine; Xi Tan of West Virginia University; and Virginia LeBaron of the UVA School of Nursing.

The researchers noted potential limitations to their study such as a lack of information on the opioids used and a lack of details on the patients’ pain assessments. They also suggest that mental health conditions such as depression may be underdiagnosed and that, as a result, the research may underestimate the percentage of patients with those conditions.

Tan disclosed potential conflicts of interest including owning stock in and receiving compensation from biopharmaceutical company Merck. Balkrishnan disclosed that he has done consulting or advising for Merck.