This section discusses pain management for metastatic breast cancer (also called advanced or stage IV breast cancer).
Learn about the management of pain related to the treatment of early breast cancer.
Controlling pain should be a standard part of treatment for all people with breast cancer. For those with metastatic cancer, it is crucial.
Although metastatic cancer cannot be cured, treatment may extend life. Pain related to treatment or the cancer itself, however, can affect your quality of life.
The goal of pain management is to have the most pain control with the least amount of medication (to limit side effects). This allows you to get the most benefit from the treatments aimed at reducing your cancer.
Let your health care provider(s) know about any pain or discomfort you have.
With metastatic breast cancer, pain can be related to treatment or the cancer itself.
Pain is not the same for everyone. Even among people at a similar stage of disease, pain can vary. Some people have more intense and more frequent pain than others.
You should never feel you need to endure pain. Even when pain is mild, it can interfere with daily life and make other side effects, such as fatigue, seem worse. Let your health care provider(s) know about any pain or discomfort you have.
Pain is usually easier to treat when you first have it. Waiting until the pain is severe before getting relief can make it harder to control and may require more medication. That is why it is so important to talk with your provider about any pain you have. Sometimes, treatment plans can be changed to reduce painful side effects.
Every visit with your health care provider should include a discussion of pain. Your provider can change the type and dose of pain medication throughout your care in response to your needs.
Your provider may suggest different types of pain control as your needs change. This ensures you are getting the most benefit from available therapies and are as comfortable as possible.
Palliative (PAY-lee-uh-tiv or PAL-ee-ay-tiv) care and pain specialists (physicians, nurse practitioners and nurses) treat pain from cancer or other causes. They can treat people with early breast cancer as well as those with metastatic cancer.
Palliative care specialists give extra care to help people maintain the best quality of life possible. They have special training in treating pain and other symptoms. They can discuss the burdens versus the benefits of different treatments for your symptoms as well as for medications or other therapies to treat the cancer. Palliative medicine is a medical specialty, just like oncology.
Anesthesia pain experts are anesthesiologists with special training in pain management. They are experts in procedures (such as injections) to relieve pain.
You may have a palliative care or anesthesia pain specialist on your treatment team. If you do not, your oncologist will likely know of a specialist in your area.
Be sure to ask your oncologist for a referral if:
Your provider should be able to follow the specialist’s recommendations and carry out your pain management plan (so you don’t need to see the specialist regularly). If the treatment is effective, you shouldn’t need to see the specialist again.
For a list of pain management centers and palliative care programs in your area, call the National Cancer Institute's Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) or the American Cancer Society toll-free at 1-800-ACS-2345 (1-800-227-2345).
For more information on palliative care, visit the American Academy of Hospice and Palliative Medicine website or the American Society of Clinical Oncology (ASCO) website.
Everyone's pain is different. So, it is important to describe exactly what you are feeling to your health care provider. This ensures he or she can offer you the best pain management possible. Certain types of pain respond better to certain types of treatment.
Providers will often ask questions (see below) to learn more about your pain so they can choose the best treatment.
Pain may change over time and it is important to let your provider know about these changes so he or she can change your treatment plan to fit your needs.
(Adapted from National Comprehensive Cancer Network, American Cancer Society and National Cancer Institute materials [46-48].)
Health care providers may use the terms neuropathic (NOOR-oh-PATH-ik), visceral (VIH-suh-rul) and somatic (soh-MA-tik) to describe different types of pain (see Figure 5.12).
Type of pain
Much of the pain related to metastatic breast cancer is due to the cancer itself. A tumor can put pressure on nerves or the spinal cord, causing injury and pain. This pain is often described as a sharp, tingling, burning or shooting feeling (neuropathic pain).
Tumors can also cause pain if they spread to organs (such as the liver) or other tissues. This pain may feel sharp, aching, cramping or gnawing (visceral pain).
When pain is caused by pressure from a tumor, the tumor itself is often treated. Surgery, chemotherapy or hormone therapy may be used to shrink the tumor so it no longer presses against nerves, the spinal cord or other organs or tissues. Surgery can also be used to prevent or control problems such as a blockage in the bowel.
Neuropathic pain can be treated with medications (see below).
If needed, an anesthesia pain specialist can sometimes inject an anesthetic (to relieve pain) and steroid (to reduce swelling) drug combination into or around a nerve to block pain. In some cases, this drug combination is injected into the fluid around the coverings of the spinal cord or into the spinal fluid itself to block the pain. It may also be given through an IV.
When breast cancer spreads to the bones (bone metastases), it can greatly affect quality of life.
This somatic pain often responds to heat, or to mild pain relievers such as ibuprofen (Advil or Motrin), naproxen (Aleve or Naprosyn) or acetaminophen (Tylenol). Although you can get these medications without a prescription, check with your health care provider before taking them. There may be medical reasons you should not take these drugs. For example, if you have (or are expected to have) a low blood count, your provider may advise you not to take ibuprofen or naproxen.
Opioids (such as morphine or oxycodone) can be added if the ibuprofen, naproxen or acetaminophen alone does not relieve the pain.
You may also be given a bone-strengthening drug therapy (see more below) to relieve the pain. These drugs are given once a month through an IV.
Bone-strengthening therapy is part of standard treatment for bone metastases. The same drugs are also used to treat pain from bone metastases. The two types of these drugs are:
Use of bisphosphonates or denosumab can :
Bisphosphonates are usually given once a month through an IV. When bisphosphonates are taken to prevent bone fractures, the frequency of treatment may be reduced to once every 3 months after a year or two of treatment. Monthly treatment for bone pain continues as long as it is effective.
Denosumab is given once a month as an injection.
In some people, bisphosphonates and denosumab can cause severe bone, joint or muscle pain in the first 1-2 days after they are given [29-30]. Any of these side effects should be reported to a health care provider right away.
Some people taking bisphosphonates need to increase their intake of vitamin D and calcium. If you develop muscle twitching or increased anxiety, ask your provider if you should take supplements to keep your vitamin D and calcium levels up.
In rare cases, with either type of drug, a disorder called osteonecrosis of the jaw may occur [29-30]. Having a full dental exam before starting treatment with bisphosphonates or denosumab may reduce the risk of this disorder . Talk with your oncologist before getting any dental procedure while you are being treated with bisphosphonates or denosumab.
Radiation therapy and surgery can be used to ease the pain of bone metastases.
Radiation therapy to the bone can relieve pain at the site of the tumor(s) and prevent fractures.
Drugs called radiopharmaceuticals (samarium (Quadramet)) or alpharadin (Xofigo)) can also treat pain from bone metastases. If you are likely to benefit from this therapy, your oncologist can refer you to a doctor who specializes in nuclear medicine.
Surgery is used to prevent or repair bone fractures.
Pain related to lymphedema can be relieved through treatment of the lymphedema itself.
Learn more about treating lymphedema.
When pain is mild to moderate, the first choice for pain relief is usually a non-opioid drug. Examples of these drugs include ibuprofen (such as Advil or Motrin), naproxen (Aleve or Naprosyn) and acetaminophen (Tylenol).
If pain persists or becomes worse, opioid drugs in combination with or instead of non-opioid drugs give added pain relief.
In general, the more pain medication you take, the more side effects you will have. Health care providers try to treat pain with the least amount of medication to limit side effects.
Although you can get most non-opioid drugs without a prescription, check with your provider before taking them.
Opioid drugs include (in order of the most commonly used):
Opioids are only available by prescription. These medications tend to have more side effects than non-opioid drugs, so they are only given after non-opioid drugs can no longer control pain.
While being treated with opioids, you should avoid alcohol, sleep aids and other medications that cause drowsiness because they can have a harmful interaction.
Some opioid medications contain both opioid and non-opioid drugs. For example, Percocet contains oxycodone (an opioid) and acetaminophen. To ensure you do not take too much of the non-opioid drug, talk with your health care provider before taking any over-the-counter medications, especially those containing acetaminophen or non-steroidal anti-inflammatory drugs (NSAID), such as ibuprofen.
Type of drug
Use of the drug
Possible side effects
Non-steroidal anti-inflammatory drugs (NSAID), such as ibuprofen (Advil, Motrin) or naproxen (Aleve or Naprosyn)
First choice for mild to moderate pain
Often used with opioid medications for severe bone and muscle pain
In large amounts, acetaminophen can cause liver damage
Side effects of other NSAIDs may include stomach and intestinal problems (such as ulcers and bleeding), problems with kidney function and worsening of heart problems
NSAIDs can also slow blood clotting
Typically used when non-opioid drugs alone do not control pain
Usually stopped gradually to avoid withdrawal symptoms
Morphine, oxycodone, hydromorphone, fentanyl, oxymorphone and buprenorphine are available as immediate release for short-term pain relief
Morphine, oxycodone, hydromorphone and oxymorphone are available as oral sustained release medications that control pain for 8-12 hours
Methadone takes about 3-5 days to get the full pain relieving effect, but then has sustained high levels of pain relief if taken 2-3 times a day
Fentanyl and buprenorphine are available in a patch form that delivers medication through the skin (patches are changed every 48-72 hours)
Constipation, drowsiness, nausea, slowed breathing and itchiness
All but constipation may go away after a few days, but some of the side effects will need treatment
Methadone can be very dangerous if not taken exactly as prescribed
People may worry about taking opioid medications, fearing side effects or addiction. However, when used as prescribed, these drugs can offer a great deal of pain relief and will not cause addiction.
Regular use of opioids almost always causes side effects, especially constipation. Your health care provider can help you prevent or control these symptoms so you can continue taking these medications. If you become overly sleepy, you or your family should contact your provider right away.
Nausea and vomiting can occur after starting opioids, but these side effects tend to go away after a few days. If you have itching or a rash, it may be a sign of an allergic reaction to opioids. Tell your provider and he or she can change your medication.
If pain increases over time, a higher dose of opioid medication may be needed. Most people build up a tolerance to the side effects of these drugs, so they can handle the side effects of increased doses more easily .
Health care providers are careful to monitor the amount of opioids they prescribe so you do not take too much.
If you abruptly stop taking an opioid medication or the dosage is suddenly reduced, you may go through withdrawal symptoms (such as pain, anxiety, nausea and diarrhea). A gradual reduction in the dose reduces the chance withdrawal symptoms will occur.
Withdrawal symptoms are a sign of physical dependence and are not related to addiction.
Physical dependence is a natural effect of regular opioid use, while addiction involves a loss of control over personal decisions about using a drug and can be related to harmful behavior.
It is very rare for addiction to develop among people taking opioids for cancer pain management, especially for those who have not had a problem with addiction in the past .
Many drugs work with pain medications to reduce pain related to metastatic breast cancer. They include antidepressants, anticonvulsants, steroids and local anesthetics. These drugs are only available by prescription.
The benefits of these medications are described in Figure 5.14. Before taking any of these medications for pain relief, it is important to discuss their potential side effects with your health care provider.
Pain relief benefit
Potential side effects
Can relieve some neuropathic pain
Dry mouth, nausea, constipation and diarrhea
Less often, sleepiness, dizziness or fainting when standing and increased sweating
Venlafaxine must be stopped gradually (cannot be stopped suddenly)
Can relieve some neuropathic pain
Liver problems and reduced red and white blood cell counts
Sleepiness, dizziness and leg swelling
Can relieve nerve swelling and bone pain
Puffiness due to fluid buildup in the body
Intolerance of sugar (diabetes-like condition)
Lidoderm patch(Lidocaine patch)
Skin rash or irritation
Adapted from National Cancer Institute materials .
There are many ways to take opioid and non-opioid pain medications. Most are pills taken by mouth.
For people who have trouble swallowing pills, some are available in liquid form or a special tablet or strip that dissolves inside the cheek. A few pain relievers can be taken in the form of rectal suppositories.
Fentanyl and buprenorphine come in a patch form. This patch is placed on the skin and releases pain medication continuously over several days.
In cases of severe pain, when oral medications do not relieve the pain or when a person cannot take medications by mouth, many drugs can be given by injection or through an IV.
Medications can be given into the vein through a port-a-cath or a peripherally inserted central catheter (PICC). These have a portable pump that delivers the medication. Some people get the medication continuously. Others can push a button to release an extra dose of medication for added relief (called patient-controlled analgesia). Still others have both continuous mediation and the option to give themselves extra doses.
In very rare cases, pain cannot be controlled by the medications described above or their side effects are too severe. In these cases, an implanted catheter can deliver the medications using a small computerized pump to the space directly outside the spinal cord (epidural pump) or to the fluid around the spinal cord itself (intrathecal pump).
The pump is carried in a backpack or "fanny pack" (for epidural pumps) or implanted under the skin (for intrathecal pumps). The pumps allow both continuous medication and patient-controlled extra doses for pain flares. The pumps are programmed to prevent an overdose.
There are many non-drug therapies you may choose to use along with pain medications. These include:
Learn more about these complementary and integrative therapies.
Joining a support group can ease some feelings of pain and provide other benefits.
Learn more about support groups and other types of social support.
Pain can affect the whole family. It can be upsetting for family, friends and other co-survivors to know a loved one has pain.
In some cases, a person living with pain may become irritable and this may strain family relationships. Social support during this time is important for family members. Spouses and partners may be in special need of support.
Hospitals and other organizations offer support programs for spouses, partners, family members and other co-survivors.
Learn more about programs for co-survivors.
Find more information for co-survivors.
At some point, you may decide to stop treatments for metastatic breast cancer. This can happen when treatment stops showing any benefit or when it greatly affects quality of life.
Once treatment is stopped, reducing any cancer-related symptoms (called palliative care) becomes the main focus, rather than just a part of treatment. Palliative care is given by your treatment team, including your palliative care specialist.
When life expectancy is six months or less, your health care provider may suggest that you enroll in a hospice home care program.
With your personal guidance, hospice can make the later stage of cancer care as comfortable as possible for you and your family.
The hospice care team works with your providers to give you the best care. Your oncologist or primary care doctor continues to guide your care and you can continue to see him or her.
This can be a very difficult time for you and your family. Your provider or hospital can arrange for counseling or a support group to help you address and manage the feelings and emotions that come with this stage of cancer care.
The National Institutes of Health (NIH) website has information on end-of-life planning and care, including questions to ask your provider.
The American Society for Clinical Oncology (ASCO) has a guide for patients and their families to help make decisions on end-of-life care.
For more on hospice, counseling and other types of support, visit the Support section.
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