Opioid-Reduction Strategy for Postoperative Pain After Breast Cancer Surgery
A Conversation With Patrick I. Borgen, MD
One persistent and potentially debilitating problem breast cancer patients suffer with is postoperative pain. Studies show that proper pain management is an essential component in the healing process, but undertreatment of pain symptoms remains an ongoing issue in the oncology community. Opioids, which are the mainstay of cancer pain management, have a variety of negative side effects, such as constipation, nausea, altered mental status, and respiratory depression, and may play a role in increasing the likelihood of cancer recurrence.
At the recent 32nd Annual Miami Breast Cancer Conference, pain management following breast surgery was an integral part of the program. The ASCO Post spoke with Conference Chairman Patrick I. Borgen, MD, who has been a vocal advocate for reducing the use of opioids in the postoperative breast surgery setting.
Meet Dr. Borgen
Please introduce yourself to our readers.
I’m currently the Chairman of the Department of Surgery at Maimonides Medical Center in Brooklyn, New York. I also founded what we call the Brooklyn Breast Cancer Project, which is the only dedicated multidisciplinary breast cancer center in Brooklyn, a city of 3 million people; most cities the size of Brooklyn have a dozen or so breast cancer programs. The leadership at Maimonides saw an unmet need and invested heavily in Brooklyn’s cancer needs. We’re set to celebrate our 10-year anniversary. Prior to Maimonides, I was the Chief Breast Surgeon at Memorial Sloan Kettering Cancer Center from 1993 until 2006.
Revolutionizing the Postoperative Experience
Please tell the readers about the successful management of postoperative pain without opioids?
During my years at Memorial Sloan Kettering, we focused heavily on extending our patients’ lives and made significant advances, which I am very proud of. Now that those advances are a reality, it is time to pay more attention to extending our patients’ quality of life. One of the easiest ways to accomplish this is by employing state-of-the-art, multimodality pain management strategies in patients undergoing breast surgery.
The nidus of this opioid-reduction story begins at this year’s annual Miami Breast Cancer Conference, which featured several talks on new pain-management approaches that reduce or eliminate the need for opioids after breast surgery.
It’s important to note, this was the 32nd Annual Miami Breast Cancer Conference, and it was the first in which we focused on the patient experience related to their pain, which speaks volumes about how this issue has been somewhat neglected by the oncology community.
I chaired several practical sessions on opioid-sparing pain control, and part of what has made this strategy possible is a vast improvement in local-regional anesthesia techniques, particularly the development of a time-released local anesthetic called liposomal bupivacaine (Exparel), which is a multivesicular liposomal-encased bupivacaine formulation. I began using this in my own practice a year ago, and it completely revolutionized the postoperative experience in my patients…irrespective of whether they had mastectomy, lymph node dissection, or lumpectomy.
This agent is a long-acting drug that offers substantial pain relief for up to 72 hours after surgery, obviating the need for opioid analgesics. My patients then escape all of the opioid-driven side effects such as constipation and nausea. Using opioid-sparing techniques such as liposomal bupivacaine also shortens hospital stays, which is another value-added benefit for our patients.
‘A Technique That Surgeons Need to Learn’
Has this particular opioid-sparing method of postoperative pain management been widely used?
The short answer is—not widely enough—but that is changing very rapidly. When we look at patient-reported pain data recorded over the past decade, we see that we have actually gotten worse in our efforts to properly manage pain in the postoperative setting. We attack the pain problem by adding more opioids and other narcotics, which just does not work. It’s a strategy that has very untoward side effects and just does not get to the root of the problem. By creating an anesthetic field prior to creating the trauma of surgery with a drug that lasts for 72 hours, we are preventing the whole inflammatory-cytokine–related pain cycle from starting. That’s key.
We’ve found that our patients who undergo bupivacaine therapy go home with a prescription for oxycodone and never break the seal on the bottle. For breast cancer patients undergoing surgery, it’s really been a game-changer—they wake up from surgery pain free. We first use bupivacaine that’s not liposomal-encased to get the immediate pain relief and then the liposomal bupivacaine injection, which kicks during the hours following surgery. So we bridge the patients with local anesthesia and then the long-acting drug. It’s a technique that surgeons need to learn because it is a methodical injection process of the surgical field. We’re also using this technique in cardiac surgery and colorectal procedures.
Is bupivacaine treatment a cost-effective way to treat postoperative pain?
The treatment is in a single 20-mL vial that can be diluted by a factor of three or four. The vial of bupivacaine we use in Brooklyn costs us about $300, which on the surface seems expensive. But when you consider that these postoperative patients leave the recovery room and go home quicker without bowel dysfunction or nausea, and with no need for opioids, we realize the downstream cost-effectiveness of the treatment. Moreover, medical reimbursement is increasingly impacted by patient satisfaction. Patients in postoperative pain are rarely “satisfied.”
Pain treatment is largely about staying ahead of the pain curve. One of the main benefits of bupivacaine therapy is that we stop the cytokine-driven inflammatory process before it starts. In breast surgery, you want to bridge the initial 3-day period of pain symptoms, at which point our patients generally move to acetaminophen or nonsteroidal anti-inflammatory drugs. And that’s what we see, which leaves me ecstatic.
Unanimous and Enthusiastic Approval
What’s been the reaction from your colleagues in the surgical oncology community about this relatively new drug technique?
Unanimous and enthusiastic approval. In the past, we had to spend a lot of time warning our patients about postoperative pain and discomfort, especially for procedures like mastectomy with reconstruction, in which about 10% to 15% of patients will go into a chronic pain syndrome that impacts every aspect of their daily lives. So we’re quite content preventing that very serious side effect. Moreover, by using opioid-sparing pain-management therapy, we’re enabling our patients to have a much quicker transition to their next course of therapy, whether its radiation therapy or chemotherapy.
Getting the Word Out
Besides the Miami Breast Conference, do you plan to actively get the word out to the surgical community about the benefits of opioid sparing postoperative pain management?
Yes, because it’s an important advance in the quality-of-life arena, and that is good for our patients. I’ve been in this wonderful field for about 25 years, and during that time, I’ve come to realize the power of breast cancer advocacy groups. So we plan reach out to these organizations and make them aware of how opioid-sparing strategies can enhance the outcomes of women undergoing breast cancer surgery. The postoperative experience is the beginning of the next step of treatment. It’s an important transition point, and we can make that transition much less difficult and much less stressful by actively employing opioid-sparing techniques. We just have to get the word out. ■
Disclosure: Dr. Borgen reported no potential conflicts of interest.