The availability of life-prolonging treatments such as hormonal therapies and other targeted chemotherapy has led to a sharp decline in breast cancer deaths in the United States.

But despite these advances, there’s a troubling discrepancy in America. Breast cancer death rates continue to remain abnormally high in the Appalachian region of the United States, and it’s partially due to a different epidemic in the U.S: opioid use.

I am an epidemiologist who specializes in cancer, and I began investigating this issue five years ago to try to come up with a picture of what was happening. One thing that struck me when I looked at health insurance and cancer registry data was the extremely high and prolonged rate of use of dangerous medications like opioids in this population, sometimes as high as 50 percent in some areas.

Life-saving hormone treatments are often associated with side effects such as pain and muscle weakness. Although opioids are not considered first-line treatment for cancer-related pain, they are increasingly used to manage unbearable pain in breast cancer survivors. And that, my research shows, could be influencing breast cancer death rates to the tune of 60 percent in rural Appalachia.

A deadly mix

The Appalachian region of the U.S. is at the epicenter of a well-documented opioid epidemic, which preceded the current national epidemic by more than a decade.

Cancer disparities have existed in Appalachia for a while, but now we need to add the opioid epidemic to the mix as well for this region. My team’s analysis found that counties with the highest opioid prescribing rates in the U.S. are disproportionately found in Appalachia, with rates 50 to 65 percent higher in Kentucky and West Virginia than over national averages. And, West Virginia has led the nation in both the total number of opioid-related deaths and opioid-related deaths among elderly cancer patients for decades.

The picture that emerges is indeed a grim one. We find many patients in Appalachia who undergo successful breast cancer treatment and then start life-prolonging hormone treatments along with opioids to manage side effects such as pain. But many (over half in some counties) continue to remain on opioids, which are usually supposed to be prescribed only for the short term, and then discontinue long-term survivorship treatments such as hormones. The reasons these women discontinue traditional treatments is not completely clear, but my colleagues and I suspect it is related to people’s dependence on opioids.

The addictive nature of the opioids, the overall feelings of hopelessness and other regional issues such as poverty and drug diversion make this a complex and complicated treatment issue and one that needs more awareness and education of both survivors and their medical providers.

What are the answers?

Now that we know this problem, what can we do for Appalachia?

Overall, greater attention is desperately needed for Appalachian women with breast cancer, who have the worst breast cancer survivorship outcomes in the U.S.

However, given the current political context in which the elimination of the Appalachia Regional Commission (ARC) is being considered, it is unclear how to best proceed with this endeavor. The ARC is charged with the economic development of Appalachia and releases periodic reports on the economic status of the region. As a result, I believe that universities and other research centers need to take a more active role in monitoring and surveillance related to both the health and economic development of the region, to aid better health policy related to this vulnerable and underserved population.

It is heartbreaking to see a woman able to beat cancer, only to die because of sub-optimal use of a life-prolonging treatment or misuse of a short-term relief treatment such as opioids. We need to work harder to educate and empower Appalachian breast cancer survivors about their treatment choices and decision-making that can be most beneficial to improving their life quality and quantity. Patient and health care professional education in Appalachia related to safe and effective use of medicines could be effective in improving patient outcomes for the most vulnerable and under-served of us all in the United States.

Rajesh Balkrishnan receives funding from the National Institutes of Health and Merck and Company.