By Jayla Burton, Program Officer

Each year at the San Antonio Breast Cancer Symposium (SABCS), the Breast Cancer Action team assesses the latest treatment research so folx can make the best-informed decisions about their care. This often includes calling out the harms associated with certain therapies or procedures intended to improve outcomes. One potential harm explored at this year’s conference was the increased risk of opioid addiction for breast cancer patients following major surgery.

When I first moved San Francisco, I immediately started working in harm reduction, a controversial industry in an already progressive arena. As a breast cancer activist and with my background in harm reduction, I am interested in exploring this topic while holding two things to be simultaneously true: we must address the growing rates of addiction and substance abuse among individuals, and also approach this problem in a way that takes into account the socio-economic systems and stereotypes surrounding addiction, and calls out the problems at the core of these issues.

In the early days of Breast Cancer Action’s work, our founders referred to breast cancer as an epidemic to create a sense of political urgency in addressing the disease. Similarly, “the opioid crisis” was a term coined in response to the staggering rate of opioid-related deaths in the U.S. In 2018, 10.3 million people misused opioids. Although there are striking differences between these now nationally acknowledged health issues, they may be interconnected.  Many people are first exposed to opioids post-surgery. Evidence shows that 10% of patients undergoing cancer-related surgeries become new chronic opioid users, more than the rate (7%) of those undergoing non-cancer related surgeries.

In addition to pain-management, nearly 25% of people living with cancer experience psychiatric disorders, including anxiety and depression. These patients may be prescribed sedative-hypnotics, like benzodiazepines, to treat tension and anxiety. In comparison to opioids, there is less known about long-term sedative-hypnotic use for breast cancer patients.

So when I saw a presentation that sought to explore the persistent use of opioids and sedative-hypnotics after mastectomy with reconstruction, I was excited to attend. In the face of a national opioid epidemic, Dr. Jacob Cogan and his research team worked to understand if misuse of controlled substances is a potential harm for women who undergo reconstructive surgery (Persistent controlled substance use following mastectomy with reconstruction surgery GS3-08).

Dr. Cogan’s study aimed to predict which breast cancer patients would develop new, persistent use of opioids or sedative-hypnotics following mastectomy with reconstruction, which are long and complex surgeries. Using a large data set from health records, researchers identified when prescriptions for opioid and sedative-hypnotics were given and refilled across three different time periods: 31 days prior to surgery; 90 days after surgery; and 365 days after surgery.

25,270 women were identified as opioid-naïve, meaning prior to surgery they were not chronically receiving opioids. The researchers found that 13.1% of these opioid-naïve patients became persistent opioid users after breast cancer-related mastectomy with reconstruction. They also found that 6.6% of patients became new persistent sedative-hypnotic users post-surgery. 

Although the study shows what percentage of mastectomy patients were prescribed and filled the prescriptions for highly addictive pain medicines following breast cancer surgery, Dr. Cogan acknowledged there is no way to determine if the 13.1% were addicted. Therefore, it is wrong to simply assume that those who have continued to use opioids for pain relief don’t actually need it.

Upon hearing this data, I immediately thought of my loved ones who have had to navigate a new breast cancer diagnosis and in the blink of an eye are faced with making life-altering decisions when it comes to their treatment and surgeries. I think about Breast Cancer Action’s membership. And I think about my future self. Although I haven’t been diagnosed with breast cancer, I often think about the hard choices I might need to make if ever in that position.

How many of the women are actually being overtreated, given around 20% of all breast cancers detected through mammography screening are considered overdiagnosis? How many of these people are opting for mastectomies that don’t improve survival but expose them to myriad surgery-related harms? How many of these women would have avoided exposure to highly addictive substances had they not been overdiagnosed and overtreated? This is a direct pipeline of access to highly addictive prescriptive drugs, including opioids.

For most breast cancer patients mastectomy offers no survival benefit, however, mastectomy with reconstruction rates continue to increase.  Although lumpectomy is medically preferred, a large proportion of patients are choosing mastectomy. In the 1990s, the U.S. National Institutes of Health released a consensus statement saying that lumpectomy plus radiation was preferred over mastectomy for early-stage breast cancer. Patients may choose lumpectomy and radiation for the benefit of a smaller surgery and keeping breast and nipple sensation.  Others may choose mastectomy because of fears about the toxicities of radiation, which they may be able to avoid if they have a mastectomy instead of lumpectomy. There is no one-size-fits-all. But one reason some patients choose a mastectomy (and increasingly even double mastectomies) is the misinformed belief that it is the best thing they can do to prevent a recurrence. Despite these misconceptions, mastectomies are not more effective at reducing risk, and lumpectomy plus radiation actually produces a very slight reduction in death rates. It is worth noting that other research has shown that Black women are more likely than white women to get mastectomies, although those numbers are changing as more young, white women have chosen mastectomies in recent years.

In addition to questions about who gets mastectomies that may not be medically necessary, we must also focus on addressing the well-known racial disparities in how pain is treated.

In their analysis to identify predictive factors of new persistent use of controlled substances, the researchers found people at an increased risk for persistent opioid use were comprised of three groups: people with Medicaid insurance, those who are receiving or have received chemotherapy, and those under the age of 65. In a white supremacist society, we cannot take data like this at face value. First, we have to grapple with implicit bias about who receives Medicaid, which is more often than not assumed to be people of color. This affects how equitably prescriptions are given—or withheld. Historically, racialized stigma has played a significant role in Black and Brown patients getting inadequate pain control.

Addiction stigma among cancer patients is real. It is important to avoid paternalistic approaches in our healthcare systems that invalidate women’s pain, especially women of color. Concerns of opioid misuse, diversion, and addiction have increased caution that may lead to clinicians being more restrictive in how they distribute medication. And it’s important that the pendulum not swing too far in the direction of “Let’s just not give people drugs.” This approach of restricting opioids for cancer patients can potentially result in undertreatment, especially for people of color who are commonly under-medicated, due to physicians’ failure to recognize pain. (Check out Disparities and Doctors’ Disconnect, a blog by our former executive director and special guest blogger, Karuna Jaggar)

Similar to breast cancer, addiction needs to be approached through a public health and social justice lens. Every study has its limitations and this study’s reliance on quantitative data doesn’t explore factors that lead to addiction. Additionally, the women in the study were not even asked if they were actually in pain and there is no data to identify which of the 13.1% of new opioid users were actually addicted. Without clear evidence about the driving factors behind persistent opioid use, many questions are unanswered, leaving room for bias towards specific populations, especially communities of color.

I appreciate that Breast Cancer Action doesn’t soft peddle the lived realities of breast cancer and acknowledges the cascade of harmful effects that come from any treatment option. Working here has given me a framework and analytical toolkit to ask critical questions such as, Does this treatment extend overall survival or improve quality of life? I know for every treatment there are tradeoffs and some of the harms that follow can be debilitating, uncomfortable, and life-threatening, including potentially life-threatening heart problems, neuropathy, and chronic pain to name a few. I also know that the same person may weigh length of life versus quality of life differently at different ages and stages of their life.

So, what’s the right approach to giving people necessary pain management, avoiding addiction, and steering clear of stereotypes that reinforce injustice in our health care systems? It is important to combat the stigma among many cancer patients of color, to consider other driving factors that lead to addiction, and to avoid addiction at the source by adjusting the breast cancer care continuum to prevent exposure to opioid drugs by reducing the number of women who are overtreated in the first place.