Opioid Use in Cancer Care and the Burden of Cancer-Related Costs: Research from the 2018 Quality Care Symposium

ASCO ® Quality Care Symposium
September 24, 2018
Monika Sharda, ASCO staff

The 2018 ASCO Quality Care Symposium, taking place September 28 and 29 in Phoenix, Arizona, brings together health care experts to share strategies for cancer care issues and integrating these methods into patient care.share on twitter You can learn more about research from this symposium by following the #ASCOQLTY18 hashtag on Twitter.

Research highlights include 5 studies: 2 studies about opioid use in cancer care and 3 studies about cancer’s financial burden.

  • People with cancer are 10 times less likely to die from opioid use than the general population

  • New approach helps lower opioid use after surgery for cancer

  • Women with metastatic breast cancer experience serious financial stress

  • Almost 1 in 5 older adults with advanced cancer face major financial problems

  • Most patients and doctors are not talking about cost before breast cancer treatment begins

New research shows that deaths linked to opioids are less common in people with cancer and highlights a new approach to lower opioid use after surgery

Opioids are a group of prescription pain medications that includes hydrocodone, morphine, oxycodone, hydromorphone, and fentanyl. These medications are often used to help people manage cancer-related pain. But many patients and health care providers are concerned about the risk of addiction when using these powerful drugs.

In recent years, the epidemic of people dying from opioid addiction and overdose has become a major concern. But there has not been much research specifically on opioid abuse among people with cancer. Two studies that will be presented at the symposium investigated this issue.  

People with cancer are 10 times less likely to die from opioid use than the general population

The first study showed that deaths linked to opioid use were much less common for people with cancer compared with the general population.

In this study, researchers looked at death certificates from the National Center of Health Statistics that listed opioids as the main cause of death and noted whether cancer was also listed as a contributing cause. From 2006 to 2016, 895 people with cancer died from opioid use compared with 193,500 in the general population. To compare changes in the number of people who died from opioid use between those with cancer and the general population, researchers measured the mortality rate. The mortality rate describes how many people out of 100,000 people will die from a specific cause. Researchers found that death from opioid use increased significantly in the general population, from 5.33 to 8.97. This means that in 2006 about 5 people out of every 100,000 people died from opioid use and that this increased to about 9 people out of every 100,000 people in 2016.

Among people with cancer, researchers found that deaths from opioid use increased very little, from 0.52 to 0.66. This means that less than 1 person per 100,000 people with cancer died from opioid use.

The study also showed that cancer-related opioid deaths were most common for the following types of cancer: lung cancer (22%), gastrointestinal cancers (21%), head and neck cancer (12%), blood and lymphatic cancers (11%), and genitourinary cancers (10%).

What does this mean? The researchers believe that many people with cancer do not need to avoid opioids for pain management based on the statistics for the general population, as people with cancer may be much less likely to abuse them.

“Patients with cancer often rely on opioids to help manage their pain during treatment and to live comfortably with the disease. Without adequate pain management, patients can be forced to take breaks from lifesaving therapy or become hospitalized due to the side effects of treatment. This study should provide both oncologists and patients with some reassurance that opioids can be a safe and effective option for managing cancer-related pain.”

—   lead study author Fumiko Chino, MD
Duke Cancer Institute
Durham, North Carolina

New approach helps lower opioid use after surgery for cancer

In the second opioid-related study that will be highlighted at the symposium, researchers used a new approach to managing pain that lowered the use of opioids after surgery by 46% in people with urologic cancers without an increase in pain or anxiety. Urologic cancers include prostate cancer, testicular cancer, bladder cancer, and kidney cancer.

According to the researchers, an estimated 6% of people with cancer who use opioids to manage pain for the first time after a surgery become addicted to these medications. To reduce the risk of opioid addiction, researchers from Stanford Health Care examined the factors that could lead to opioid abuse. They looked at patients’ daily opioid use, levels of pain, and levels of anxiety for people recovering from surgery. They also developed new plans to manage pain that used different combinations of non-opioid medications.

The researchers then created a 2-part approach for 443 patients participating in this study that changed prescribing patterns and increased communication about pain management.

For the first part of the approach, health care providers prescribed non-opioid medications to people after surgery. People still received opioids if the non-opioid drugs did not control their pain. But the opioids were started at low doses and were only increased if needed.

For the second part of the approach, providers were trained to talk about pain management in a more comprehensive way with their patients. They started by discussing non-opioid medication options as well as the possible side effects of opioids. The study’s researchers noted that this was different from the usual approach of immediately asking patients whether they wanted pain medication, meaning opioids.

With this new approach, researchers found that people who received non-opioid pain medicine did not have more pain or anxiety than those who received opioids within 48 hours of surgery.

What does this mean? The researchers believe that this new pain management approach can reduce opioid use after cancer surgery. In turn, this could reduce the risk of opioid addiction and abuse.

“While opioids can be an effective pain management tool for cancer patients, there is a risk of addiction, particularly for people who have recently undergone surgery. We found that when [doctors] have conversations with patients about pain control, including non-opioid therapies available and the potential risks associated with opioids, they appreciate being involved in their own care, and, subsequently, have a reduced need for opioid medications.”

—   lead study author Kerri Stevenson, NP
Stanford Health Care
San Francisco, California

Studies find people with cancer face financial problems and do not discuss them with their doctors

Coping with the costs of cancer care can be difficult, from the time of your diagnosis to after treatment. Worry about high costs can cause stress and anxiety for people with cancer and their loved ones. The cost-related challenges a person has during medical care is often called “financial toxicity.” Three studies that will be presented at the symposium explored how financial toxicity affects 2 groups of patients: people with breast cancer and older adults.

Women with metastatic breast cancer experience serious financial stress

A large nationwide study found that people with metastatic breast cancer face a significant burden from cancer-related costs. This financial burden was especially high for people who did not have health insurance.

In this study, researchers surveyed 1,054 women about their financial situation. The online survey was about 20 minutes long and included questions about health insurance status, having cost-related discussions with doctors, financial problems after treatment, strategies for coping with costs, and emotional well-being.

Of the participants, about one-third did not have health insurance. Those without insurance were more likely to refuse or delay treatment than the women who had insurance (96% compared with 36%) and be contacted by a collections agency (92% compared with 30%).

On the other hand, participants with health insurance reported higher cost-related emotional distress (41% compared with 24%) and more financial stress on their families from the cancer (36% compared with 19%).

What does this mean? The study suggests that people with metastatic cancer may face a substantial burden from cancer costs that includes but also goes beyond health insurance status. Patients should talk with their health care team about the costs and ask them for resources to help them cope.

“Our study shows that the financial toxicity of cancer is alarmingly high in many metastatic breast cancer patients and that having health insurance doesn’t protect patients from the psychosocial impact of high cancer costs. High co-insurance and deductibles mean that many patients are still shouldering an enormous financial burden out-of-pocket and feeling anxious about what it will mean for their own and their families’ finances and financial legacy.”

—   lead study author Stephanie B. Wheeler, PhD, MPH
University of North Carolina Chapel Hill
Chapel Hill, North Carolina

Almost 1 in 5 older adults with advanced cancer face major financial problems

A new study showed that 18% of older adults with advanced cancer have financial problems from the cost of treatment that affects their care, quality of life, and mental health.

For this study, 542 people ages 70 to 96 were asked to complete a questionnaire about their financial situation. The researchers at the University of Rochester classified people as experiencing financial toxicity if they answered “yes” to any of these 3 questions:

  1. Have you ever delayed medications due to cost?

  2. Have you ever had insufficient income in a typical month for food or housing?

  3. Have you ever had insufficient income in a typical month for other basic needs?

Compared with people who were not experiencing financial toxicity, those who did were more likely to have severe anxiety (18% compared with 7%), depression (27% compared with 21%), and a lower quality of life (41% compared with 22%). The results also showed that only half of the people who had financial toxicity had talked about it with their doctor.

What does this mean?  Older adults are particularly vulnerable to financial toxicity from a cancer diagnosis, and it is important for patients and doctors to talk with each other about this. Having a discussion can create an opportunity to connect patients with a social worker or financial specialist. These professionals can suggest resources and strategies to help reduce a patient’s financial burden.

“The majority of patients with cancer are older, which means they’re living on restricted incomes and often don’t want to burden either their caregivers or kids. Their spouses may also have their own health care needs, and their finances have to cover many expenses other than cancer care, including food, medications, and housing. This is a vulnerable group we haven’t paid enough attention to as a society, but really need to, especially as the older population continues to grow.”

—   senior author Supriya Gupta Mohile, MD, MS
University of Rochester Medical Center
Rochester, New York

Most patients and doctors are not talking about cost before breast cancer treatment begins

This third study about cost that is being highlighted at the symposium reported that many women with breast cancer who face serious financial burden have not talked with their health care team about treatment costs even though they would prefer to do so.

The study included 607 women with a history of breast cancer (stages 0 to III). They were asked to complete an 88-question online survey about their experiences with treatment costs and whether they preferred talking with their doctors about financial problems. Even though 79% of the women said they preferred understanding costs before beginning treatment, 78% of them did not discuss costs with their health care team.

About 95% of the women in the study had either private insurance or Medicare and an annual household income of at least $74,000. This is higher than the average annual income in the United States. The survey also showed that 43% of the women considered costs when making decisions about treatment. And 40% wanted their doctors to consider costs when making recommendations about treatment.

Part of the survey asked participants to describe the seriousness of their financial burden as 1 of the following: none, slight, somewhat, significant, or catastrophic. About 15% chose “catastrophic.” Researchers also looked at the out-of-pocket treatment costs each woman had to pay. Out-of-pocket costs are expenses not covered by insurance that a patient must pay. The median out-of-pocket treatment-related costs were $3,500. The median is the midpoint, which means that half of the women had costs that were less than $3,500 and half had costs that were more than $3,500. In this study, 25% reported out-of-pocket costs of at least $8,000; 10% said they were at least $18,000; and 5% said they were at least $30,000.

Women who were more likely to have a high financial burden were those who had extensive surgery or a more advanced stage of the disease. Those who were less likely to have a high financial burden were older, had been diagnosed with cancer less recently, had a higher household income, and had lower out-of-pocket costs. The 16% who said they discussed costs with their health care team were more likely to have stage II or III breast cancer (56% compared with 40%), were less likely to be depressed (24% compared with 30%), and had less health insurance than those who did not talk about costs.

What does this mean? Doctor-patient communications about the real costs of cancer care are important to have. Results of this study show that even people with certain advantages, such as higher income or health insurance, face significant cost-related effects of breast cancer. The researchers suggest that people without such advantages may experience an even greater risk of financial harm.

“In an era of rising cancer treatment costs, we don’t routinely discuss the financial implications of cancer care with women embarking on treatment. Many treatment options for breast cancer are comparable in their effectiveness, but their costs can vary. As women consider various cancer treatment options, information about costs could help them make more informed decisions about which therapies are best for them.”

—   lead study author Rachel Adams Greenup, MD, MPH
Duke University Medical Center
Durham, North Carolina 

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