Mindy Waizer

Patients who received chemotherapy, actively smoked and drank alcohol, and were diagnosed with head and neck cancer reported significantly higher rates of opiate use, according to study results presented at the American Society of Clinical Oncology (ASCO) 2018 Palliative and Supportive Care Symposium.

Moreover, the researchers found that 70 percent of patients with cancer used opiates after radiation, and survivors who were treated with radiation for more than four weeks had higher rates of opiate use just one year after finishing treatment.

Opioids are commonly prescribed for the management of moderate to severe chronic pain experienced by patients undergoing treatment for cancer, yet few statistics are available to assess how patients with cancer are affected by prescription opioid use. “We don’t know how many cancer patients died from prescription opiates and there is little published data about their prescribing patterns,” the researchers wrote.

 in patients with cancer, investigators from the University of Texas Southwestern Medical Center (UTSW) analyzed opioid prescription data from 6,424 patients with lung, breast and head and neck cancer to assess their demographics, cancer type, treatment modality, concurrent medicines, substance abuse history and survival.

The researchers saw widespread use among genders, with 76 percent of 2,112 men and 67 percent of 4,307 women who reported to use these medications, of which 8 percent had three or more different opiates prescribed. Hydrocodone was the most commonly used (67 percent), followed by morphine (12 percent), fentanyl (9 percent), oxycodone (7 percent), and hydromorphone (6 percent).

In total, 18.7 percent of women and 15.9 percent of men received gabapentin — a neuropathic pain reliever that is commonly prescribed to those addicted or at risk of addiction to opioids.

Of the 850 patients who received chemotherapy and radiation, 696 required opiates (82 percent) compared to 68 percent of those who did not receive chemotherapy. Patients with head and neck cancer reported the highest rate of opioid abuse (77 percent) compared with those with breast (65 percent) or lung cancer (70 percent).

Lastly, the researchers found that of the 2,643 patients who used alcohol, 2,001 received opiates (76 percent) compared to 67 percent of those who did not use alcohol. Among active smokers, 76 percent used opiates versus 67 percent of those who never smoked.

Articles

Social Habits, Cancer Type and Treatment Impact Increased Rates of Opioid Use

By SAKETH GUNTUPALLI, M.D., FACS, FACOG, AND MARYANN KARINCH

What is the impact of gynecological or reproductive cancers on a woman’s intimate relationships? The sensitive and oft-neglected subject of sexual intimacy receives the spotlight treatment in "Sex and Cancer: Intimacy, Romance, and Love After Diagnosis and Treatment."

Many more women are surviving gynecologic cancers than ever before. This book helps readers mitigate outcomes and overcome challenges of sexual dysfunction after a cancer diagnosis; reassess the priorities in an intimate relationship to support her struggle, healing and libido; and learn to interact with the professionals tasked with saving lives and enhancing those areas affected by cancer diagnosis and treatment. Written by a survivor of endometrial cancer and her gynecological oncologist, the book features personal stories from survivors that offer insight, comfort and suggestions for addressing questions about intimacy and sexual function that are often left unexpressed.

"Surviving the Storm" is a book for people who want to tell the story of how they have been affected by cancer. It provides prompts to guide survivors in thinking about their experience, and how to tell their unique story of surviving or living with cancer. It helps them discover their authentic voice. The author, Cheryl Krauter, integrated her experience as an existential humanistic psychotherapist with her personal journey as a breast cancer survivor in shaping her book. A contemplative perspective inspires readers to explore themes of love, belonging and personal meaning related to their cancer journey. Personal stories of cancer survivors are highlighted, and poetry and writings related to cancer are interspersed throughout the book.

This young adult book, based on a true story, tells the tale of a 12-yearold girl named Maddie, who has a quirky sense of humor and loves making her classmates laugh by slapping on fake mustaches. When Maddie starts tripping as she walks and her hand starts curling up at her side, her mother takes her to the doctor, who confirms Maddie has a brain tumor. In an instant, her world is turned upside down. With scary medical tests and surgery ahead of her, as well as typical sixth-grade problems, Maddie uses her friendliness, positive attitude, imagination and her fake mustaches to battle her challenges. She even gets an unexpected surprise when she receives hundreds of photos from friends, family members, and even complete strangers wearing fake mustaches to cheer her on. Sensitively told, Mustaches for Maddie highlights the power of humor, hope and love to strengthen the spirit and help people cope with the trials that cancer brings.

A look at three cancer-related books to help you "survive the storm." 

Book Corner

Jean Lehmann of Fort Collins, Colorado, was looking forward to the date of her last chemotherapy treatment. She hoped that would mark the end of her breast cancer experience, and she could move on with her life.

Nothing could have been further from what happened.

The last treatment was the hardest, leaving Lehmann feeling sicker than ever before. But, she discovered, there was a limit to the post-chemotherapy support she would get from her medical doctors. “I had amazing health care, but it comes to an end,” Lehmann says. “The doctors have done what they can do. I first had this sense that I’m going to be done, and I’m going to be well, and I’m going to be me again — but that’s not always the case. I realized, if I am going to try to return to who I am &mdash; physically, mentally, spiritually, intellectually &mdash; I have to work on this.”

A friend recommended a free support group called FIERCE: Functional & Fit, Independent, Energized, Restored, Confident & Empowered, led by Alene Nitzky, Ph.D., RN, OCN. An oncology nurse, Nitzky is also an exercise trainer certified by the American College of Sports Medicine and the American Cancer Society. She uses her unique blend of expertise to help survivors on the road to wellness.

“People get through treatment and don’t have an idea of how they’re going to feel,” Nitzky says. “They don’t have an idea of what’s realistic for themselves. We talk about what reasonable goals might be. We set some time goals — six months, a year. We talk about being flexible with that.”

FIERCE is no ordinary support group. Members meet in a donated space in a gym, the Raintree Athletic Club in Fort Collins. This appeals to Lehmann, who would rather not spend time in a medical setting now that she has completed treatment. She also appreciates being among survivors who do not dwell on their illness but understand her issues.

“We don’t really talk about having cancer,” Lehmann says. “I want to be Jean first. But I’m with people who — if something comes up &mdash; they all get it. Because they’ve been there.”

Over the past three years, the FIERCE program has evolved beyond stretches and exercises to become a tasting menu of fitness techniques. Nitzky brings in speakers to introduce survivors to tai chi, biofeedback, qi gong, Pilates and yoga — each offering a different approach to physical recovery from the effects of cancer or its treatment &mdash; as well as a nutritionist to discuss diet.

“People might benefit from talk support groups for a little while, but they need to move on, have some normalcy in their lives and expand their horizons,” Nitzky says. “Our group also helps with the cognitive aspects [of recovery]. Survivors might have brain fog, feel anxious or feel like they’re not thinking clearly. Interaction, exercise and learning new things is so good for them.”

Nitzky takes a holistic perspective, incorporating relaxation techniques and advice on dealing with aftereffects and anxiety. She tries to personalize topics and exercises to the participants, based on their requests and their conditions.

As a certified cancer exercise trainer, Nitzky understands survivors’ specific needs. “For example, if a person has low platelets, you don’t want them to do any impact activities,” she says. “If their immune system is weak, you don’t want them around a lot of other people. If they have lymphedema or they’re at risk for lymphedema, you have to be careful about the kinds of exercises you do, so you don’t trigger that.”

Cancer treatment affects survivors’ abilities, so she considers whether a participant has recently finished radiation or had surgery, for example. She realizes that they may have lost muscle mass or developed anemia after chemotherapy, and their bone marrow may not have recovered. “You have to be careful about how hard people push themselves, because you don’t want to deplete their muscles and their heart of oxygen. You want to make sure they ease into it,” Nitzky says.

Jane Kinney, who is five years past her surgery for stage 4 thyroid cancer, attended the FIERCE support group and found that expertise valuable. Nitzky identified medical issues that arose after Kinney’s surgery, during which 59 lymph nodes were removed. “One of my cheeks would swell way up. The surgeon basically just dismissed it,” Kinney says. “I didn’t know, but it was just lymphedema. Alene was the one who identified it. She knew what it was right away.

“I also would sometimes have pain all over my body,” Kinney says.” I thought, ‘That’s just the way it is.’ But when I mentioned it to Alene, [she] suggested that I might need more vitamin D. She told me to talk to my doctors, and I did, and they gave me a pretty high dose of vitamin D. Alene made my quality of life so much better.”

FIERCE grew out of Nitzky’s health coaching business, Cancer Harbors, which she established four years ago as a way to use her knowledge and experience to benefit people with cancer. Before striking out on her own, Nitzky had worked as an oncology nurse and, before that, as a personal trainer and exercise educator.

“As a nurse, I was hanging bags of chemo[therapy] most of the time and feeling like I wasn’t really using all my skills. I was listening to the patients while they were sitting in their chairs, and they have all these questions, all these needs that aren’t being addressed,” she said.

That led to Nitzky’s aha moment: “I have a background in health and wellness, and I had worked with people who had serious health conditions. As I listened, I realized, ‘I would be able to serve their needs. I would be able to work with survivors, because I have a background in recreation, health, exercise and oncology. I can put all this together. It makes sense. Everything in my life has pointed to this.’”

And so Cancer Harbors was born. In this six-month skill-building program for self care, Nitzky coaches survivors to be advocates for their own health. She helps clients understand what to ask providers and encourages them to gain the confidence to ask those questions.

“A lot of people go in to the doctor’s office thinking, ‘The doctor is the expert, and I really don’t know anything; this is like a different language to me,’” Nitzky says. “But really, though the doctor is the expert on medicine, the patients are the experts on themselves. You have to be able to go in with this attitude that, ‘OK, they have something to bring to this relationship, and I have something to bring to this relationship, and our shared purpose is to get me as well as possible.’”

Through the program, survivors improve their cancer literacy, learn about the best online sources for care, and find out what products and services are available. Nitzky also helps survivors set goals, define their values and understand what is most important to them.

Alene Nitzky helps survivors transition from the end of treatment to the beginning of wellness.

Establishing a Safe Harbor for Survivors

Last year, the bladder cancer community saw an abundance of change and major advances in the treatment of the disease.

In particular, there were five Food and Drug Administration (FDA) approvals for checkpoint inhibitors in both the first and second line setting.

And now, moving forward, patients with bladder cancer have even more to look forward to.

, Daniel J. George, M.D., director of the Prostate and Urologic Cancers Program at Duke Cancer Institute discussed the role of immunotherapy, its continued integration into standards of care, and what else the future holds for the treatment of bladder cancer.  

How important is immunotherapy in the future of bladder cancer treatment, and why?

Immunotherapy in bladder cancer is here to stay. There’s no doubt in my mind that this is going to become more and more a part of our frontline therapies, whether it’s in combination with chemotherapy or in sequence with chemotherapy. We’re going to see more and more patients receiving immunotherapy as monotherapy for bladder cancer. But I think what’s going to evolve in this field and what we’re excited about is the opportunity to use immunotherapy now perhaps in some novel settings to change the outcome. I think one of the real exciting opportunities is bladder-sparing approaches, so avoiding having to do a cystectomy and using chemotherapy, radiation therapy, and immunotherapy to help control this disease in situ and to create the immune recognition necessary to get cures and long-term complete responses in patients who have their tumor left intact, and consequently allow us to leave their bladder intact.

Most solid tumors now, we’re doing organ-sparing approaches for esophageal, head and neck, many other GI settings, lung cancer, etc. This is a setting I think we need to revisit, and I think it’s something that’s going to happen. I think the other area that’s exciting for bladder cancer will be combination immunotherapies, and these are going to happen on the back end. These are going to happen, again, in platinum-refractory settings or even our checkpoint-refractory settings where we’re going to revisit immunotherapy perhaps in combination with some additional targets. To me, this may be more biomarker-driven in the future and understanding what in the immune system is really driving that immune escape and overcoming that. But I think in bladder cancer now that we’ve established PD-1, PD-L1 as a standard, that’s what we’ll be building off of in the future rather than cisplatinum-based regimens.

What are some of the hurdles to expect when testing immunotherapy in bladder cancer? 

As exciting as this field is with where checkpoint inhibitors have taken us now, there’s a lot of work to be done. There’s still the 70 percent to 75 percent of patients who don’t respond to a PD-1, PD-L1 inhibitor, and we need to figure out how to get them responsive. We also need to understand how to get some of these partial responders to a more durable effect, we need to understand what to add to the checkpoint inhibitor, and we need to understand how to use these in earlier disease settings. There are some studies looking at checkpoint inhibitors in more superficial disease, but that may be risky. That certainly would be expensive, and it may be toxic in a subset of patients. So, understanding how to use other forms of immunotherapy or perhaps even localized immunotherapy in some of those settings will be key.

Integrating immunotherapy around our standard surgery and radiation will be important, and then ultimately, recognizing when immunotherapy can stop. How long you have to treat patients with immunotherapy in this disease who are in a long-term remission will be another really important question. So, I think there’s a lot of questions to still get after.

What do you think the timeline is for real progress in bladder cancer treatment?

There’s going to be more than immunotherapy for bladder cancer. There are genetic alterations that are actionable, targetable. Some of those are under active investigation now. Others will emerge. How to integrate precision medicine with immunotherapy to make both of those more effective will be another critical step in the new few years ahead. So, I’m excited about bladder cancer. It was hard to say that five years ago, but now we’re excited about bladder cancer and we’re excited to see where we can take this field. And we have something really positive to build off of. I think you’re going to see continued progress in this field for at least the next five to 10 years.

Daniel J. George, M.D., discusses the role of immunotherapy, its continued integration into standards of care and what else the future holds for the treatment of bladder cancer.

Mindy Waizer

Social Habits, Cancer Type and Treatment Impact Increased Rates of Opioid Use

Book Corner

Establishing a Safe Harbor for Survivors

The Future of Bladder Cancer Treatment

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