Could Perioperative Opioid Use Increase the Risk of Cancer Progression and Metastases?

Influence of exogenous opioids on the acute inflammatory response in the perioperative period of oncological surgery: a clinical study

BACKGROUND

Recently, opioids have been related to trigger changes in cytokine release and tumor angiogenesis processes, influencing tumor growth, metastasis, and recurrence.

METHODS

This is a prospective randomized clinical study to test whether if exogenous opioids used in the anesthesia during cancer surgery can affect the systemic inflammatory and immunological patterns. Patients were randomly allocated to the OP (opioid...inclusive) or OF (opioid-free) anesthesia group. A total of 45 patients were selected, being carriers of prostate, stomach, pancreas, bile ducts, breast, colon, lung, uterus, kidneys, or retroperitoneum tumors. Plasma levels of IL-4, IL-12, IL-17A, and TNF-.., and their oxidative stress profile before and after surgery were evaluated in both groups. In vitro tests were performed by using healthy donor blood incubated with each isolated drug used in patients... anesthesia for 1...hour, the same cytokines were measured in plasma.

RESULTS

There was a significant reduction in lipid peroxidation in both groups. Patients from OF group had a significant consumption of IL-12 in the perioperative period. The other cytokines evaluated did not vary. It was also observed a significant correlation between IL-12 and TNF-.. levels in the OF-post group. Except for atracurium, all tested drugs led to a reduction in IL-12 levels.

CONCLUSIONS

This study demonstrated that there is a reduction of IL-12 in the OF-post patients, suggesting acute consumption and that this seems to be a general mechanism of anesthetic drugs, as demonstrated in vitro. Also, these findings bring us to reflect if IL-12 changes may influence the disease progression and recurrence.

Morphine counteracts the effects of paclitaxel in triple-negative breast cancer cells

Background & objectives

Several studies have provided evidence that opioids may play a role in cancer recurrence and metastasis. Multiple research data indicate that morphine can act as a proliferative or suppressive agent on tumour cells depending on the applied concentration. Therefore, this study was aimed to investigate whether the presence of clinically relevant concentrations of morphine has any effect on the efficacy of paclitaxel, a widely used chemotherapeutic drug, on the viability and apoptosis of human triple-negative breast cancer cell line.

Methods

MDA.MB.231 cells were treated with paclitaxel in the presence or absence of morphine and examined for cell proliferation by the MTT assay. In addition, the effect of morphine on paclitaxel-induced apoptosis was investigated by flow cytometric assay and by the ratio of Bax/Bcl-2 mRNA expression levels with quantitative real-time (qRT)-PCR.

Results

Morphine significantly increased the proliferation of breast cancer cells at low concentrations (0.1-2.5 μM) but higher concentrations showed cytotoxic effect. Pre-treatment with 0.1 or 1 μM of morphine decreased the paclitaxel-induced cytotoxicity, the proportion of apoptotic cell, and the ratio of Bax/Bcl-2 mRNA expressions.

Interpretation & conclusions

Our data suggest that morphine promotes breast cancer cell viability at clinically relevant plasma concentrations and reduces the apoptotic effect of paclitaxel. This interaction may be very important in clinical settings; however, more studies are needed to explore the plausible mechanisms of interaction and to correlate such findings through in vivo animal studies as well as clinically.

Does recreational drug use influence survival and morbidity associated with laryngeal cancer

Background

The use of opioids is considered a risk factor for laryngeal cancer. A retrospective study was performed to explore the relationship between recreational drug exposure and laryngeal cancer.

Methods

Patients diagnosed between the 1st of January 2013 and the 31st of December 2017 using ICD-10 CD-32 coding were identified from the Head and Neck Multidisciplinary Team database. We divided the study population into two cohorts (RD and non-RD) and compared the demographics, morbidity, and outcomes of these two populations. In addition, we performed case-matched analysis to control for potential confounding factors including gender, alcohol use and cigarette smoking.

Findings

329 patients in Glasgow, Scotland were included with a mean age of 64.96 ± 10.94 and a follow-up of 24 ± 13.91 months. Of these, 39 reported recreational drug use (RD). RD was associated with younger age (53.0 vs. 66.6, p<0.001) at diagnosis with laryngeal cancer. A greater proportion of tumours occurred in the supraglottic subsite (p=0.041). Furthermore, these patients were more likely to undergo tracheostomy (RR=2.50, 95% CI: 1.41-4.44, p=0.008) and laryngectomy (RR=2.25, 95% CI: 1.57-3.21, p<0.001). Recreational drug users were more likely to require enteral feeding support (RR= 1.44, 95% CI: 1.13-1.84, p=0.02) during oncological treatment. No survival differences were noted at 1, 2, or 3-years (_plog-rank=0.83). Case matched analysis correcting for smoking, alcohol and gender confirmed that recreational drug users were younger at diagnosis with a predilection for the supraglottic subsite.

Conclusion

Recreational drug use is associated with an increased burden of disease and morbidity in laryngeal cancer. We suggest that clinicians view recreational drug exposure as a red flag in those with suspected laryngeal cancer regardless of patient age.

The Effects of Anesthetics on Glioma Progression: A Narrative Review

There are many established factors that influence glioma progression, including patient age, grade of tumor, genetic mutations, extent of surgical resection, and chemoradiotherapy. Although the exposure time to anesthetics during glioma resection surgery is relatively brief, the hemodynamic changes involved and medications used, as well as the stress response throughout the perioperative period, may also influence postoperative outcomes in glioma patients. There are numerous studies that have demonstrated that choice of anesthesia influences non-brain cancer outcomes; of particular interest are those describing that the use of total intravenous anesthesia may yield superior outcomes compared with volatile agents in in vitro and human studies. Much remains to be discovered on the topic of anesthesia's effect on glioma progression.

Antitumor Anesthetic Strategy in the Perioperatory Period of the Oncological Patient: A Review

The stress response triggered by the surgical aggression and the transient immunosuppression produced by anesthetic agents stimulate the inadvertent dispersion of neoplastic cells and, paradoxically, tumor progression during the perioperative period. Anesthetic agents and techniques, in relation to metastatic development, are investigated for their impact on long-term survival. Scientific evidence indicates that inhaled anesthetics and opioids benefit immunosuppression, cell proliferation, and angiogenesis, providing the ideal microenvironment for tumor progression. The likely benefit of reducing their use, or even replacing them as much as possible with anesthetic techniques that protect patients from the metastatic process, is still being investigated. The possibility of using "immunoprotective" or "antitumor" anesthetic techniques would represent a turning point in clinical practice. Through understanding of pharmacological mechanisms of anesthetics and their effects on tumor cells, new perioperative approaches emerge with the aim of halting and controlling metastatic development. Epidural anesthesia and propofol have been shown to maintain immune activity and reduce catecholaminergic and inflammatory responses, considering the protective techniques against tumor spread. The current data generate hypotheses about the influence of anesthesia on metastatic development, although prospective trials that determinate causality are necessary to make changes in clinical practice.

Opioid-Sparing Multimodal Analgesia Protocol for Lumpectomy Patients Results in Superior Postoperative Pain Control

Background

We sought to determine if lumpectomy patients who received perioperative opioid-sparing multimodal analgesia reported less pain when compared with those who received traditional opioid-based care.

Study Design

A prospective cohort of patients undergoing lumpectomy who received an opioid-sparing multimodal analgesia protocol [no opioids group (NOP)] was compared with a large cohort of patients who received traditional care [opioids group (OG)]. In-hospital and discharge opioids were compared using oral morphine equivalents (OMEs). Postoperative day one and week one pain scores were compared using the Kruskal–Wallis test.

Results

Overall, 1153 patients underwent lumpectomy: 634 patients received the protocol (NOP), and 519 patients did not (OG). Median pain scores were significantly lower in the NOP cohort when compared with the OG cohort the day after surgery (2 vs. 0, p < 0.001) and the week after surgery (1 vs. 0, p < 0.001). NOP patients were significantly less likely to report severe pain (7–10 on a 10-point scale) the day after surgery compared with OG patients (15.7% vs. 6.9%, p = 0.004). Patients in the NOP cohort were discharged with a median of zero OMEs (range 0–150), while patients in the OG were discharged with a median of 90 OMEs (range 0–360; p < 0.001).

Conclusion

Implementation of an opioid-sparing multimodal analgesia protocol for lumpectomy patients resulted in superior pain control without a routine opioid prescription. Surgeons can improve their own patients’ outcomes while addressing the larger societal issue of the opioid crisis by adopting similar protocols that decrease the quantity of opioids available for diversion.

Brain Cancer Progression: A Retrospective Multicenter Comparison of Awake Craniotomy Versus General Anesthesia in High-grade Glioma Resection

BACKGROUND

High-grade gliomas impose substantial morbidity and mortality due to rapid cancer progression and recurrence. Factors such as surgery, chemotherapy and radiotherapy remain the cornerstones for treatment of brain cancer and brain cancer research. The role of anesthetics on glioma progression is largely unknown.

METHODS

This multicenter retrospective cohort study compared patients who underwent high-grade glioma resection with minimal sedation (awake craniotomy) and those who underwent craniotomy with general anesthesia (GA). Various perioperative factors, intraoperative and postoperative complications, and adjuvant treatment regimens were recorded. The primary outcome was progression-free survival (PFS); secondary outcomes were overall survival (OS), postoperative pain score, and length of hospital stay.

RESULTS

A total of 891 patients were included; 79% received GA, and 21% underwent awake craniotomy. There was no difference in median PFS between awake craniotomy (0.54, 95% confidence interval [CI]: 0.45-0.65 y) and GA (0.53, 95% CI: 0.48-0.60 y) groups (hazard ratio 1.05; P<0.553). Median OS was significantly longer in the awake craniotomy (1.70, 95% CI: 1.30-2.32 y) compared with that in the GA (1.25, 95% CI: 1.15-1.37 y) group (hazard ratio 0.76; P<0.009) but this effect did not persist after controlling for other variables of interest. Median length of hospital stay was significantly shorter in the awake craniotomy group (2 [range: 0 to 76], interquartile range 3 d vs. 5 [0 to 98], interquartile range 5 for awake craniotomy and GA groups, respectively; P<0.001). Pain scores were comparable between groups.

CONCLUSIONS

There was no difference in PFS and OS between patients who underwent surgical resection of high-grade glioma with minimal sedation (awake craniotomy) or GA. Further large prospective randomized controlled studies are needed to explore the role of anesthetics on glioma progression and patient survival.

INFLUENCE OF DIFFERENT TYPES OF ANESTHESIA FOR LAPAROSCOPIC HYSTERECTOMY ON THE DYNAMICS OF STRESS HORMONES

The aim of the study – to evaluate the influence of different variants of anesthesia, including low-opioid (LOA) and opioid-free anesthesia (OFA), on the dynamics of the stress response during laparoscopic hysterectomy. Materials and methods: 102 patients were randomly allocated into 3 groups: 37 women assigned to receive a standard opioid-based anesthesia (OBA group), 33 women – LOA group and 32 patients OFA group. Results: The patients of OFA group after induction and intubation of the trachea showed a significant (p<0.05) increase in cortisol level by 155.4 % and 160.9 % compared with the OBA group and LOA group. After completion of the hysterectomy, regardless of the variant of anesthesia, the level of cortisol exceeded the preoperative one (pOBA=0.116, pLOA=0.049, pOFA=0.043). Two hours after surgery with standard anesthesia (OBA group) there was a further increase in the concentration of cortisol in the blood, exceeding the initial values by 142.9 % (p=0.043). Patients in the LOA group and OFA group tended to decrease cortisolemia. The changes in adrenaline & glucose levels were somewhat similar. Conclusion: Use of OFA is accompanied by an aggravation of the stress response at the stage of hysterectomy, which is manifested by an increase in the level of adrenaline and cortisol. The most adequate perioperative protection is inherent in low-opioid anesthesia, which is accompanied by a lower release of stress hormones during hysterectomy and in the postoperative period. Opioid-based anesthesia provides adequate intraoperative protection, but is accompanied by insufficient postoperative analgesia.

Opioid-free anesthesia-caution for a one-size-fits-all approach

Post-operative pain management should ideally be optimized to ensure patient’s mobilization and ability to partake in effective pulmonary exercises for patient’s early recovery. Opioids have traditionally been the main mode for analgesia strategy in the perioperative period. However, the recent focus on opioid crisis in the USA has generated a robust discussion on rational use of opioids in the perioperative period and also raised the concept of “opioid-free anesthesia” in certain circles. Opioid-related adverse drug events (ORADE) and questionable role of opioids in cancer progression have further deterred some anesthesiologists from the routine perioperative use of opioids including their use for breakthrough pain. However, judicious use of opioid in conjunction with the use of non-opioid analgesics and regional anesthetic techniques may allow for optimal analgesia while reducing the risks associated with the use of opioids. Importantly, the opioid epidemic and opioid-related deaths seem more related to the prescription practices of physicians and post-discharge misuse of opioids. Focus on patient and clinician education, identification of high-risk patients, and instituting effective drug disposal and take-back policies may prove useful in reducing opioid misuse.

Outcomes of Patients With Advanced Gastrointestinal Cancer in Relationship to Opioid Use: Findings From Eight Clinical Trials

BACKGROUND

This study assessed the patterns of opioid use among patients with advanced gastrointestinal cancers who were included in 8 clinical trials and evaluated the impact of opioid use on survival outcomes of included patients.

METHODS

Deidentified datasets from 8 clinical trials evaluating first-line systemic treatment of advanced gastrointestinal cancers were accessed from the Project Data Sphere platform (ClinicalTrial.gov identifiers: NCT01124786, NCT00844649, NCT00290966, NCT00678535, NCT00699374, NCT00272051, NCT00305188, and NCT00384176). These trials evaluated patients with pancreatic carcinoma, gastric carcinoma, hepatocellular carcinoma (HCC), and colorectal carcinoma. Multivariable logistic regression analysis was used to evaluate factors predicting the use of opioids. Kaplan-Meier survival estimates were used to compare survival outcomes in each disease entity among patients who did or did not receive opioid treatment. Multivariable Cox regression analysis was then used to further assess the impact of opioid use on survival outcomes in each disease entity.

RESULTS

A total of 3,441 participants were included in the current analysis. The following factors predicted a higher probability of opioid use within logistic regression analysis: younger age at diagnosis (odds ratio [OR], 0.990; 95% CI, 0.984-0.997; P=.004), nonwhite race (OR for white vs nonwhite, 0.749; 95% CI, 0.600-0.933; P=.010), higher ECOG score (OR for 1 vs 0, 1.751; 95% CI, 1.490-2.058; P<.001), and pancreatic primary site (OR for colorectal vs pancreatic, 0.241; 95% CI, 0.198-0.295; P<.001). Use of opioids was consistently associated with worse overall survival (OS) in Kaplan-Meier survival estimates of each disease entity (P=.008 for pancreatic cancer; P<.001 for gastric cancer, HCC, and colorectal cancer). In multivariable Cox regression analysis, opioid use was associated with worse OS among patients with pancreatic cancer (hazard ratio [HR], 1.245; 95% CI, 1.063-1.459; P=.007), gastric cancer (HR, 1.725; 95% CI, 1.403-2.122; P<.001), HCC (HR, 1.841; 95% CI, 1.480-2.290; P<.001), and colorectal cancer (HR, 1.651; 95% CI, 1.380-1.975; P<.001).

CONCLUSIONS

Study findings suggest that opioid use is consistently associated with worse OS among patients with different gastrointestinal cancers. Further studies are needed to understand the underlying mechanisms of this observation and its potential implications.

Evaluation of Receptor Affinity, Analgesic Activity and Cytotoxicity of a Hybrid Peptide, AWL3020

In the present contribution we report design, synthesis and evaluation of receptor affinity, analgesic activity and cytotoxicity of a hybrid peptide, AWL3020. The peptide includes two pharmacophores, one of δ-opioid receptor (δOR) agonists and one of neurokinin-1 receptor (NK1R) antagonists. The design was motivated by the desire to obtain a compound with strong analgesic action and potential additional antiproliferative action. The compound displays high δOR affinity (IC50 = 29.5 nM). On the other hand, it has only poor affinity for the NK1R (IC50 = 70.28 μM). The substance shows good analgesic action which is however weaker than that of morphine. Regarding the effect on proliferation, the compound exhibits no pro-proliferative action in the assayed range. In higher concentrations, it has also cytotoxic activity. This effect is however not selective. The strongest effect of AWL3020 was found for melanoma MeW164 cell line (EC50 = 46.27 μM in reduction of cell numbers after a few days of incubation; EC50 = 37.78 μM in MTT assay).

Immunomodulatory Effects of Surgery, Pain, and Opioids in Cancer Patients

Surgery is the mainstay of therapy for canine and human solid cancers. Alarmingly, evidence suggests that the process of surgery may exacerbate metastasis and accelerate the kinetics of cancer progression. Understanding the mechanisms by which cancer progression is accelerated as a result of surgery may provide pharmacologic interventions. This review discusses surgery-induced cancer progression. It focuses on immunomodulatory properties of anesthesia and opioids and evidence that studies evaluating the role of opioids in tumor progression are indicated. It concludes by discussing why companion animals with spontaneously arising cancer are an ideal model for clinical trials to investigate this phenomenon.

Morpheus and the Underworld-Interventions to Reduce the Risks of Opioid Use After Surgery: ORADEs, Dependence, Cancer Progression, and Anastomotic Leakage

BACKGROUND

Perioperative pain management is a key element of enhanced recovery after surgery (ERAS) programs. A multimodal approach to analgesia as part of a coordinated ERAS includes the reduction of opioid use. This review aims to discuss opioid-related adverse events, strategies to reduce opioid use after surgery, and the relevance to the present "opioid crisis" in North America.

METHODS

A literature review of the pharmacology of opioid drugs, perioperative opioid reduction strategies, and the potential public health benefit was performed. This included current ERAS guidelines on multimodal analgesia, randomized controlled trials on perioperative analgesia, and intervention studies to decrease opioid use, misuse, and diversion in North America.

RESULTS

Reduction of perioperative opioid usage has been endorsed by joint clinical practice guidelines on the management of postoperative pain from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists. Interventions as part of an "opioid bundle" that can be incorporated into ERAS protocols include multimodal analgesia, regional anesthesia, opioid sparing drugs, carbon dioxide humidification during laparoscopy, changing opioid prescription practices, patient and physician education, and proper disposal of unused opioid medications.

CONCLUSION

There are substantial benefits in incorporating opioid reduction strategies into ERAS and clinical practice guidelines. These include faster return of function and mobility, and decreased opioid-related adverse drug events (ORADEs), postoperative morbidity and mortality, and length of hospital stay. Improved oncological outcomes after cancer surgery may be an additional benefit. Evidence-based interventions can also reduce opioid abuse and diversion in the community.

Impact of enhanced recovery on oncological outcomes following minimally invasive surgery for rectal cancer

BACKGROUND

Oncological outcomes of locally advanced rectal cancer depend on the quality of surgical and oncological management. Enhanced recovery pathways (ERPs) have yet to be assessed for their oncological impact when used in combination with minimally invasive surgery. This study assessed outcomes with or without an ERP in patients with rectal cancer.

METHODS

This was a retrospective analysis of all consecutive adult patients who underwent elective minimally invasive surgery for primary rectal adenocarcinoma with curative intent between February 2005 and April 2018. Both laparoscopic and robotic procedures were included. Short-term morbidity and overall survival were compared between patients treated according to the institutional ERP and those who received conventional care.

RESULTS

A total of 600 patients underwent minimally invasive surgery, of whom 320 (53·3 per cent) were treated according to the ERP and 280 (46·7 per cent) received conventional care. ERP was associated with less overall morbidity (34·7 versus 54·3 per cent; P < 0·001). Patients in the ERP group had improved overall survival on univariable (91·4 versus 81·7 per cent at 5 years; hazard ratio (HR) 0·53, 95 per cent c.i. 0·28 to 0·99) but not multivariable (HR 0·78, 0·41 to 1·50) analysis. Multivariable analysis revealed age (HR 1·46, 1·17 to 1·82), male sex (HR 1·98, 1·05 to 3·70) and complications (HR 2·23, 1·30 to 3·83) as independent risk factors for compromised overall survival. Disease-free survival was comparable for patients who had ERP or conventional treatment (80·5 versus 84·6 per cent at 5 years respectively; P = 0·272).

CONCLUSION

Treatment within an ERP was associated with a lower morbidity risk that may have had a subtle impact on overall but not disease-specific survival.