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Focus on Impact of Polypharmacy on Cancer Survivors

Submitted by Michelle Kirschner MSN, RN, ACNP,BC, ACNP; Survivorship & Supportive Services Program

Cancer survivors are more likely to be on multiple medications.  This is due to the consequence of side effects from cancer and its treatment such as mental health challenges, fatigue, pain, peripheral neuropathy and sleep disturbance. In addition, data has supported that cancer patients are more likely to have co-morbidities since lifestyle and risk of cancer are interconnected. [1] For example, risk factors such as smoking and obesity which are risk factors for cancer are also risk factors for chronic diseases.  Many of these co-morbid conditions are also treated pharmacologically.  The trend for polypharmacy in older adults is addressed in the NCCN guidelines for older adults. [2]  Even younger cancer survivors were prescribed more medications than younger individuals without a cancer history. Review of patients with cancer receiving chemotherapy for solid tumors have shown that one or more drug-drug interactions were observed in roughly 27% of all patients [3]

Polypharmacy has consequences for cancer survivors and can lead to medication related harms such as noncompliance and drug interactions. [3] As patients are prescribed more medications, they are more likely to have elevated anticholinergic burden which can impact cognitive function in cancer patients. Many of these drugs are listed in the Beers Criteria. These criteria was developed in 1991 to assist prescribers in identifying medications that should be avoid in older adults. [4] https://www.pharmacytoday.org/article/S1042-0991(19)31235-6/pdf  These guidelines were adopted by the American Geriatric Association (AGS) in 2011 and were last updated in 2019.  The NCCN Older Adult Guidelines also provides a comprehensive list of medications and reference the Beers Criteria as a main source for recommendations. The Beers Criteria are divided into three categories for older adults: potentially inappropriate medications to avoid, medication to avoid with certain diseases or syndromes and medications to be used with caution.   Many of these are used within the cancer population to address side effects related to cancer and its treatment.  This list includes SSRI, antipsychotics, benzodiazepines, non-benzodiazepines sedative hypnotics and opioids. 

There are multiple ways to reduce polypharmacy in the cancer population.   NCCN guidelines recommend additional medication review for patients taking 5 or more medications.  This review should focus on adherence, medication duplication, appropriate use and potential drug interactions.  Involvement of pharmacists in this process has been shown to have favorable impact.   Oncology Acute Care for Elders (OACE) study explored the benefit of an outpatient pharmacist-based intervention.  This study found that 53% of cancer patients had a change in their medication regimen and 28% had an identified medication discontinued. [5]

Implementation of non-pharmacologic treatment options can be beneficial in avoiding or reducing the dose for medications used to treat specific symptoms.  For example, NCCN guidelines recommend cognitive behavioral therapy for insomnia prior to starting hypnotics.  Patient with ongoing pain syndromes may benefit from early interactions with physical therapy or Physical Medicine and Rehabilitation physicians.  Integrative medicine also presents treatment options such as acupuncture and massage that have shown benefit in addressing cancer related side effects including peripheral neuropathy, chronic pain, sleep and hot flashes. [6]   

The survivorship and supportive care clinic can partner with patients during and after treatment to assist them in understand their non-pharmacologic treatment options.  Patient input directs that overall goals are incorporated to create a personalized treatment plan.  Follow up with the survivorship visits allow for reassessment of symptoms and reassessment of recommendations based on outcomes. 

  1. Hsu, C.D., Nichols, H.B. & Lund, J.L. Polypharmacy and medication use by cancer history in a nationally representative group of adults in the USA, 2003–2014. J Cancer Surviv (2021). https://doi-org.uc.idm.oclc.org/10.1007/s11764-021-01059-x
  2. NCCN.  Older adult guidelines.  https://www.nccn.org/professionals/physician_gls/pdf/senior.pdf
  3. Keats, M.R., Cui, Y., DeClercq, V. et al. Burden of multimorbidity and polypharmacy among cancer survivors: a population-based nested case–control study. Support Care Cancer 29, 713–723 (2021). https://doi-org.uc.idm.oclc.org/10.1007/s00520-020-05529-3
  4. Fixen, D.R.. 2019 AGS Beers Criteria for older adults. PharmacyToday, 43-54 (Nov 2019). 2019 AGS Beers Criteria for older adults (pharmacytoday.org)
  5.  Lichtman SM, Boparai MK. Geriatric medication management: Evaluation of pharmacist interventions and potentially inappropriate medication (PIM) use in older (>=65 years) cancer patients. J Clin Oncol 2009;27:9507. Available at: http://meeting.ascopubs.org/cgi/content/abstract/27/15S/9507.
  6.  Han, Q. Q., Fu, Y., Le, J. M., Ma, Y. J., Wei, X. D., Ji, H. L., Jiang, H., Gao, Y., & Wu, H. (2021). The Therapeutic Effects of Acupuncture and Electroacupuncture on Cancer-related Symptoms and Side-Effects. Journal of Cancer, 12(23), 7003–7009. https://doi.org/10.7150/jca.55803

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