New data show that in patients with breast cancer undergoing a lumpectomy or excisional biopsy, nonsteroidal anti-inflammatory drugs and opioids deliver comparable pain control.

“Routine discharge with opioids is unnecessary in patients undergoing lumpectomy/excisional biopsy procedures,” said Tracy-Ann Moo, MD, an assistant attending at Memorial Sloan Kettering Cancer Center (MSKCC), in New York City, presenting at the 2020 annual meeting of the Society of Surgical Oncology.

Dr. Moo noted that in 2017, there were 47,600 deaths from drug overdose in the United States, with approximately 17,000 attributed to prescription opioids. “A number of studies demonstrate that opioids are overprescribed in the postoperative setting and that unused tablets become available for diversion and misuse in the community,” Dr. Moo said.

While lumpectomy and excisional biopsy are commonly performed ambulatory breast procedures that are not associated with a significant amount of pain after discharge, a survey of over 600 members of the American Society of Breast Surgeons showed that approximately 80% of surgeons routinely prescribe opioids after lumpectomy (Ann Surg Oncol 2020;27[4]:985-990).

In August 2018, as part of a quality improvement initiative, MSKCC started eliminating routinely prescribed opioids in patients undergoing lumpectomy or excisional biopsy. Instead, they sent patients home with a prescription for the NSAID diclofenac, unless NSAIDs were contraindicated in a patient.

The new study retrospectively evaluated the opioid prescription rate after change from routine discharge with opioids to diclofenac and determined the NSAID failure rate by assessing the number of patients who were discharged with NSAIDs who were prescribed opioids for pain control within seven days of the procedure. The study also compared patient-reported post-discharge pain scores in the time period where opioids or diclofenac were routinely prescribed.

At MSKCC, all ambulatory breast surgery patients are treated with intraoperative ketorolac, IV acetaminophen, and an injection of both short- and long-acting local anesthetic at the surgical site. All opioid prescriptions are placed electronically, allowing doctors to query the electronic medical record to document opioid prescriptions at or within seven days of discharge. Patient-reported post-discharge pain scores are documented in the Recovery Tracker, a post-discharge survey completed via the MSKCC patient portal on postoperative days 1 through 5, using a scale of 0 to 10 with 0 being no pain, 1 to 3 being mild pain, 4 to 6 being moderate pain, 7 to 8 being severe pain, and 9 to 10 being very severe pain.

The researchers examined lumpectomy or excisional biopsy patients from December 2017 to August 2018 (n=328), when routine opioids were prescribed, and from August 2018 to June 2019, when routine NSAIDs were given (n=461). Among the two study periods, there was no difference in age, BMI, American Society of Anesthesiologists physical status, or race. In addition, there was no difference between the two groups in terms of intraoperative characteristics, except more patients who were prescribed NSAIDs received more acetaminophen (97% vs. 94%). A greater proportion of patients treated in the opioid period received greater than 10 morphine milligram equivalents (10.3% vs. 5.6%). Whereas 96% of patients received opioids in the routine opioid period, only 14% received opioids in the routine NSAID period. The NSAID failure rate was 1%.

“Compared to the study period where we routinely prescribed opioids, there was no difference in the proportion of patients reporting moderate or severe pain when we switched to routine NSAIDs,” Dr. Moo said. Further, there was a nonsignificant trend toward more frequent reports of moderate/severe pain among patients discharged with an opioid prescription versus an NSAID over both time periods.

According to Shelley Hwang, MD, the vice chair of research and chief of breast surgical oncology at Duke University, in Durham, N.C., the new study is practice-changing and demonstrates that opioids can be avoided in most cases of lumpectomy or excisional biopsy.