ketorolac to reduce recurrence

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Fallleaves
Fallleaves Member Posts: 806
edited May 2018 in Surgery - Before, During, and After

There have been several studies done showing that the use of ketorolac (an NSAID analgesic commonly used in surgery) in breast cancer surgery, dramatically reduces the relapse rate of patients in the first few years after surgery, and improves their overall survival.

"The expected prominent early relapse events are all but absent. In the 9-18 month period, there is fivefold reduction in relapses. If this observation holds up to further scrutiny, it could mean that the simple use of this safe and effective anti-inflammatory agent at surgery might eliminate most early relapses." http://www.ncbi.nlm.nih.gov/pubmed/23992307

"In conservative breast cancer surgery, the intraoperative use of NSAIDs (ketorolac or diclofenac) was associated with an improved DFS {hazard ratio (HR)=0.57 [95% confidence interval (CI): 0.37-0.89], P=0.01} and an improved overall survival (OS) [HR=0.35 (95% CI: 0.17-0.70), P=0.03]." http://www.ncbi.nlm.nih.gov/pubmed/24464611

So, I'm finished with surgery, but I'm wondering if it's possible for patients who are now going in for surgery to request ketorolac. If I'd known about it I sure would have asked for it! I also saw there is a clinical trial that is recruiting participants, but it is located in Belgium. http://clinicaltrials.gov/show/NCT01806259

This is not a new drug; it has been around for 20 years. I don't know why it isn't being offered to breast cancer patients, unless there's a good reason not to. But I don't have a medical background, so I'd be interested in input from those of you who do.

Links to BCO threads that are related to this topic:

Topic: Toradol (ketorolac) for Recurrence Reduction July 2015, by sas-schatzi

https://community.breastcancer.org/forum/73/topic/...

Topic: Paravertebral Nerve Block and Propofol Sept. 2015, by Falleaves

https://community.breastcancer.org/forum/73/topic/834546?page=1#idx_15

Topic: Effects of opioids on cancer progression Sept. 2015, by Falleaves

https://community.breastcancer.org/forum/73/topic/835291?page=1#idx_

Topic: Anesthesia and recurrence of cancer Sept. 2015, by Fallleaves

https://community.breastcancer.org/forum/73/topic/835244

Topic: NSAIDS and Breast Cancer Sept. 2015, by 123JustMe

https://community.breastcancer.org/forum/73/topic/835343


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  • MsMay
    MsMay Member Posts: 13
    edited March 2014

    I had dbl mast 2 weeks ago, my dr prescribed percocets and ketorolac. I haven't been taking the ketorolac because it didn't seem to help any with the pain. Going to research it more.

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  • geewhiz
    geewhiz Member Posts: 1,439
    edited March 2014

    Studies showed this WAY back. I wish I understood why more docs aren't all over this. I have requested a consult with the anasthesia doc prior to every surgery to make sure it is used.

    I will add that one of my PS's said it seems to create more blood flow during his surgeries, so it can be an uphill battle. 

    Thanks for the link - I'm going to forward to a few of my docs!

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  • Fallleaves
    Fallleaves Member Posts: 806
    edited March 2014

    Geewhiz, I'd love to hear what your doctors have to say. I realize there aren't any large studies on ketorolac and BC recurrence, but at the same time this is an established drug that doctors don't seem to have a problem prescribing right now. It's not like it would even be off-label! I did see a study that compared ketorolac to morphine, and it mentioned 8% greater bleeding with ketorolac, so I guess for people with bleeding issues that would be a consideration. But then why not just prescribe it for pain management afterwards, like MsMay?

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  • Amoc1973
    Amoc1973 Member Posts: 158
    edited March 2014

    I just posted this same thing. Sorry I didn't see this or I wouldn't have reposted. I'm an anesthesia provider in real life. It should be given before incision. Also ask about a Paravertebral block. Looks like it may reduce recurrence too. It's also amazing for pain post op. I did both the toradol & the block. Definitely ask! Some don't like toradol because it inhibits platelets---so could cause more bleeding in surgery. So it is usually used at the end of the procedure. From what I understand it needs to be before incision. google. Print the studies. Take them to your surgeon. Also show your anesthesia provider. 

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  • Amoc1973
    Amoc1973 Member Posts: 158
    edited March 2014

    Btw...plastic surgeons usually HATE toradol. But I insisted. I had no problems w bleeding. I also give it to most of my breast cancer pts (unless contraindicated for a particular pt) pre-incision after ok'ng it with the surgeon. I had no idea about this until a surgeon friend told me. 

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  • Fallleaves
    Fallleaves Member Posts: 806
    edited March 2014

    Amoc1973, I'm so glad to see you are offering the ketorolac/toradol and paravertebral nerve blocks to your patients. I also read the study showing nerve blocks added to general anesthesia dramatically reduced recurrence and mortality. Just AFTER my surgery! (http://www.sciencedaily.com/releases/2013/10/131015191057.htm) When I read that, I emailed my BS and asked her about it, and she said they don't do nerve blocks with sentinel node biopsies. But other people on these boards said they had them, and you apparently offer them, so I don't know why she's acting like it can't happen. Anyway, when I told my husband about the ketorolac and nerve blocks he said, "You should have done your research." I think he was trying to be funny, but if he'd been in striking distance I would have hit him! I think most patients don't know about these studies. I just wish more providers were being proactive like you. 

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  • Amoc1973
    Amoc1973 Member Posts: 158
    edited March 2014

    Please don't beat yourself up. I had NO idea about this. I worked w an awesome breast surgeon who a couple years ago started getting very verbal about "toradol before incision". So I picked her brain. I hadn't heard of it & I do anesthesia for breast cancer ALL the time. When my diagnoses happened I went to her. She then informed me about the blocks showing same thing. I then read about it. Lots of surgeons & anesthesia providers aren't even aware of these things. The big cancer places are I'm sure. I had an ax node dissection because we already knew I had pos nodes. But I guarantee you I would've asked for the block for just sentinal node too. I do understand why in a pain perspective it might not be deemed neccassary w snb. But....sometimes you have SNB then pathology walks in & says 'it's positive' then you end up w/ an ax node dissection that wasn't planned. That is ALWAYS  as possibility. So.......yes they're done for SNB. But again. Don't focus on 'what ifs'. You're Gonna do great. The odds are def in your favor! 

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  • Fallleaves
    Fallleaves Member Posts: 806
    edited March 2014

    Amoc1973, thanks for the kind words! I just hope the word gets out about adding toradol and doing nerve blocks. Anything that gives women better odds is absolutely worth doing. I think I'm going to write a letter to my BS, who is with Johns Hopkins. She heads the BC center where I live (Columbia, MD), and I would love to see these options offered to her patients going forward.  

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  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited May 2016

    Bump

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  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited July 2016

    Bumpity bump

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  • 123JustMe
    123JustMe Member Posts: 385
    edited May 2018
    • More research on Toradolfrom 123JustMe May 21, 2018 02:23PMKetorolac Lowers Breast Cancer Risk in Patients With Elevated BMI
      Journal of the National Cancer Institute.
      Save Recommend Share Get Topic Alerts TAKE-HOME MESSAGE
      • This retrospective series was designed to evaluate the impact of intraoperative nonsteroidal anti-inflammatory drug use on breast cancer recurrence. Patients receiving intraoperative ketorolac (but not diclofenac) appeared to have a reduced risk for distant recurrence (HR, 0.59; P = .03).
      • The reduction in distant recurrences was particularly pronounced in patients with an elevated BMI given ketorolac.– Neil Majithia, MD
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  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited May 2018

    Thanks 123, great article


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  • 123JustMe
    123JustMe Member Posts: 385
    edited May 2018

    Question is any one going to do anything with the information?

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  • beach2beach
    beach2beach Member Posts: 996
    edited May 2018

    In August I will be a year out from a double mastectomy. At my PS appt prior to surgery I still was in shock as it was only 4days since I was dx'd but I remember he said he doesn't use painkillers but uses a nerveblock. I had no idea what to expect. After surgery and in my room the nurse told me no painkillers but they had me hooked up to Ketorolac(she told me it was like having heavy duty Tylenol) and I had been given a nerve block prior to surgery and I would not probably feel anything for a day or so. Honestly, it all worked well because luckily I did not have the pain that many women seem to experience after mastectomy. I walked out the hospital next day. Sent me home with a few Ketorolac pills in case I needed them, but never did.

    So I'm hoping the combo will prove to help in the long run too. Wouldn't that be great for all of us...

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  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited May 2018

    Beach sounds to me your Doc was using the most forward & promising plan of action. It's almost like he was reading here.

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  • beach2beach
    beach2beach Member Posts: 996
    edited May 2018

    Right? I was taken aback when I found out no painkillers. Not that I would take them, I figured I would need them. But nope. I did not know about the Ketorolac until after I had the mastectomy done and stumbled on your post about it and read about its possible connection to a reduced recurrence. Thanks to you and Fallleaves for great info.

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  • Meg101
    Meg101 Member Posts: 175
    edited May 2018

    Sas - I read your thread (from 2014?) about Toradol/Ketorolac. You had just discovered the study, posted it, and were very excited. You knew years ago that Toradol/Ketorolac would be of great interest to BC patients. You even said someone needs to get the word out about how well it works against recurrences if used BEFORE the incision. I'll bet the information about Toradol is being suppressed due to liability issues concerning the rare possibility of increased bleeding. Anyway, I just want to thank you for the wealth of information you provide to all of us. The studies you post along with your own knowledge from being a medical professional is more than valuable. And I must add, your writing style is quite entertaining. Keep it up. Meg

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  • Meg101
    Meg101 Member Posts: 175
    edited May 2018

    123JustMe - I'm so glad you posted the article about Toradol/Ketorolac. The more BC patients know about this, the more we can create consumer pressure to get the medical industry off their butts to be more proactive with this drug. It not only can save lives, it also makes BC surgical recovery less painful. Thanks again. Meg

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  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited May 2018

    Meg and Beachie...........Oh YAY, ToradAL IS AND AMAZING DRUG.

    There is a clinical study going on with a sister drug and DUH another drug.

    I haven't kept up to posting. I was frustrated by low viewings.

    What is happening I think, is that the medical community is keeping abreast of the Torardol connection, blocks, and no opioids. without the absolute scientific proof. These are three items, that can be done in surgery without big modifications of practice. Simple to accomplash

    The problem is that action is getting ahead of the science.

    When the docs see something so promising for treatment. AND they can fit it into their treatment modality. It's to them "OKAY". Fore Example. Rainnyc went to methinks Sloan Kettering, they were already using the modality. YOOOHOOO

    Where that becomes a problem is when we see a drop in statistics without knowing who is using the modality, there can be a false narrative to survival statistics.

    Obviously, we don't care. We care about prevention and survival.


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  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited May 2018

    Meg, OMD what a nice post. Frankly, I lost faith. I track number of viewings. That is done by going to the top and click on forums link. That brings up all topics in the forum . Next to each topic you can see how often a topic is viewed. The composite thread only has 600(<) That's horrible, really.

    We all worked so hard in 2015. The package of links is entered in each topic thread.

    What I didn't realize till a couple of days ago is the composite thread wasn't linked. DUH, total bummer. Not sure it made a difference for the active researcher. The need to know was on the thread.with links.

    If you can make a suggestion regarding the composite thread forum placement, please, do.

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