Management of Pain Related to the Metastatic Breast Cancer

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This section discusses pain management for metastatic breast cancer. For information related to early breast cancer, see Management of Pain Related to Treatment of Breast Cancer.

What is Pain Management?

Controlling pain should be a standard part of treatment for all people with breast cancer. For those with metastatic disease, it is crucial. If you are living with metastatic breast cancer, you should not hesitate to let your health care provider(s) know about any pain or discomfort you are having.

Although metastatic cancer cannot be cured, treatment can prolong life. Pain related to the cancer or cancer treatment, however, can affect the quality of your life. The goal of pain management is to have the most pain control with the least amount of therapy and thus, the fewest side effects. This allows you to get the most benefit from the treatments directed at reducing your cancer.

Pain Control and Palliation for Metastatic Breast Cancer

With metastatic breast cancer, pain can be related to treatment or to the cancer itself. Pain is not the same for everyone. Even among people at a similar stage of disease, pain can vary in intensity and frequency. You may feel that this pain is simply a part of your treatment and you should be strong and endure it. However, even when it is mild, pain can interfere with daily life and make other side effects, such as fatigue, seem worse.

Pain is usually easier to treat when it first starts. Waiting until pain is severe before seeking relief can make the pain more difficult to control and require more medication to treat it effectively. Sometimes treatment plans can be changed to reduce painful side effects, so it is important to tell your health care provider about any pain that you are feeling.

Health Care Providers and Palliative Care or Pain Specialists

Every visit with your health care provider should include a discussion of your pain management. Your health care provider will likely change the type and dose of medication throughout your care. He/she may also recommend other types of pain management as your needs change. This ensures that you are getting the most benefit from available therapies and are as comfortable as possible.

Some health care providers are more experienced at treating pain than others. If your provider is unable to control your pain or if you are having distressing side effects from the pain medicines, you should ask for a referral to a palliative care or pain specialist. Palliative care specialist (physicians and nurses) treat people with cancer at any point in their treatment course, not just those with advanced cancer. Palliative medicine is a specialty of medicine, just like oncology. Most cancer centers will have palliative care specialist as part of their treatment teams. And, your oncologist will likely know of a palliative care specialist in your area. For a list of pain management facilities and 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).

Describing Your Pain

Everyone's pain is different so it is important to describe what you are feeling to your health care providers. This will ensure that they can offer you the best pain management. Different types of pain respond better to different types of treatment.

Health care providers will often ask questions to gain a better understanding of your pain so they can decide the best treatment for your pain (see below). Pain may change as time goes on and it is important to let your health care providers know about these changes so that they can change your treatment plan to fit your needs.

Questions Your Health Care Provider May Ask You About Pain

1. Where is the pain?
2. When did the pain start?
3. How long has the pain lasted?
4. Has the pain changed in any way?
5. Is there anything that makes the pain worse or better?
6. On a scale from 1-10, with 10 being the worst, how would you describe your pain? What is your pain level now? Most of the time? Is that level acceptable to you?
7. What is the intensity of the pain (mild, moderate, severe, etc.)? What is your pain level now? Most of the time? Is that level acceptable to you?
8. Describe the pain (throbbing, burning, tingling, pressure, etc.).
9. Does the pain come and go or do you feel it at all times?
10. Does the pain affect your ability to perform or enjoy daily activities?
11. Does it interfere with your sleep? Your appetite? Does it affect your mood?
12. What do you think is causing the pain?
13. How do you feel about pain control?

Questions to Ask Your Provider About Your Pain

1. What can be done to relieve my pain?
2. What can we do if the drugs do not work?
3. What other options do I have for pain control?
4. What side effects may happen with the pain medications?
5. What can be done to manage these side effects?
6. What side effects do I need to report to you (the health care provider)?

(Adapted from World Health Organization, National Comprehensive Cancer Network, American Cancer Society and National Cancer Institute materials [123-126].)

Types of pain

Health care providers may use the medical terms neuropathic (NOOR-oh-PATH-ik), visceral (VIH-suh-rul) and somatic (soh-MA-tik) to describe different types of pain. These are described in Figure 5.7 below.

Figure 5.7. Types of pain 

Pain Related to a Tumor

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 that 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.

If neuropathic pain resists initial drug treatments (see below), a drug combination containing an anesthetic (to relieve pain) and a steroid (to reduce swelling) can be injected into or around a nerve to block pain. A few people will need this drug combination injected into the fluid around the spinal cord to block the pain.

Bone Pain

When cancer spreads to the bones, it can greatly affect quality of life. Bone strengthening therapy helps lower the risk of fractures in women with bone metastases. Acting as bone stabilizers, a group of drugs called bisphosphonates are now part of standard treatment for women with bone metastases. Intravenous use of the bisphosphonates, pamidronate (Aredia) or zoledronic acid (Zometa) once per month has been shown to decrease the rate of fractures and pain. It can also reduce the need for radiation therapy and surgery. Some people receiving these drugs will need to increase their intake of vitamin D and calcium. If you develop muscle twitching, or increased anxiety, you should ask your health care provider if you should take supplements to keep your calcium levels normal.

Though rare, a serious jawbone disorder called osteonecrosis may occur in some people who take bisphosphonates. Treating dental infections prior to treatment with bisphosphonates may reduce this risk [29].

Radiation therapy and surgery can also be used to ease the pain of bone metastases. Radiation therapy to the bone can relieve pain and prevent fractures. Radiopharmaceuticals are drugs attached to sources of radiation. They are given intravenously and go to the site of the cancer in the bone where they act to decrease bone pain. These drugs are helpful in some people. Surgery is also used to prevent or repair bone fractures.

Pain Related to Lymphedema

Pain related to lymphedema after treatment for breast cancer can be relieved through treatment of the lymphedema itself. For more on treatment of lymphedema, visit the After Treatment chapter.

Non-opioid and Opioid Medications Used to Treat Metastatic Breast Cancer Pain

When pain is mild to moderate, the first choice for pain relief is most often a non-opioid drug. Examples of these medications include ibuprofen (such as Advil or Motrin) and acetaminophen (Tylenol). If pain persists or becomes more severe, 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 have. Health care providers try to treat pain with the least amount of medication to limit side effects. Although most non-opioid drugs are available without a prescription, it is important to discuss their use with your health care provider first.

Opioid drugs, including morphine, oxycodone hydromorphone, methadone and fentanyl, are available by prescription. These medications tend to have more side effects and therefore are given only after non-opioid drugs no longer can control pain. While being treated with opioids, alcohol, sleep aids and other medications that cause drowsiness should be avoided as they can have a dangerous interaction with opioids.

Some opioid medications contain both opioid and non-opioid drugs. For example, Percocet consists of acetaminophen and oxycodone (an opioid). To ensure that you do not take too much of the non-opioid medication, talk to 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.

Figure 5.8. Non-opioid and opioid medications used to treat metastatic breast cancer pain

Potential Barriers to Pain Management with Opioids

People may have concerns about some types of pain management, especially opioid medications, because of the risk of addiction or worry over side effects. However, when used as prescribed, these drugs can offer a great deal of pain relief.

Side effects

Regular use of opioid medications almost always causes side effects, especially constipation. Your health care provider can help you prevent or control these symptoms so that you can continue these medications.

Nausea and vomiting can occur after starting opioids, but these side effects tend to go away after a few days. Itching or a rash may indicate an allergic reaction to opioids. If these occur, tell your health care provider and he/she can change your medication.

If pain increases over time, a higher dose of opioid medication may become necessary. As most people build up a tolerance to the side effects related to these drugs, they can handle the related side effects of increased doses more easily [127,128].

Fear of addiction

Health care providers are careful to monitor the amount of opioids that they are prescribing so that you do not take too much. If you abruptly stop taking an opioid medication or the dosage is suddenly reduced, you may go though withdrawal symptoms, such as pain, anxiety and nausea. A gradual reduction in the dose of medication reduces the chance that 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 the drug and can be related to destructive behavior. Addiction among people taking opioids for pain management of cancer is very rare [127,128].

Policy barriers

Because opioids have the potential to become addictive and can be sold illegally, some states have laws in place that restrict their use. Health care providers in these states can be hesitant to aggressively treat pain for fear of breaking these laws. Susan G. Komen for the Cure® in collaboration with other health information and advocacy organizations is working to remove these policy barriers for optimal pain care. For more information on these policies, view the report Achieving Balance in State Pain Policy: A Progress Report Card (Third Edition), prepared by the University of Wisconsin Pain and & Policy Studies Group.

Other Medications Used to Treat Metastatic Breast Cancer Pain

Many drugs work with pain medications to reduce pain related to metastatic breast cancer. These include antidepressants, anticonvulsants, steroids and local anesthetics. All of these drugs are available by prescription only. The benefits of these medications are described in Figure 5.9. Before taking any of these medications for pain relief, it is important to discuss their potential side effects with your health care provider.

Figure 5.9. Other medications used to treat metastatic breast cancer pain

How Pain Medications are Given

There are many ways to take medications for pain. Most are pills taken by mouth. For people who have trouble swallowing pills, some are available in liquid form or a special formulation that dissolves inside the cheek. A few pain relievers can be taken in the form of rectal suppositories. Fentanyl comes in a patch form, similar to a nicotine patch. This patch is placed on the skin and releases pain medication continuously for 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 into a vein or underneath the skin with a small needle. Medications can also be given into the vein through a port-a-cath or a peripherally inserted central catheter (PICC). These have a portable pump that continuously delivers the medication. A person can push a button to release extra medication for added relief (called patient-controlled administration). In very rare cases, pain cannot be controlled by the medicines described above or their side effects are too severe. In these cases, medications can be given continuously through an implanted catheter that delivers them into the fluid around the spinal cord. The catheter is either connected to a small computerized pump containing the medications, that is also implanted under the skin or to an external pump that can be carried in a backpack or "fanny pack". These special computerized pumps allow both a continuous rate of pain medication and patient-controlled administration of added medication for pain flares. The pumps are programmed to prevent an overdose.

Complementary Therapies (non-drug therapies) for Pain

There are many therapies that you may choose to use in combination with pain medications. These include physical therapy, acupuncture, nutrition, relaxation techniques, massage therapy, hot and cold therapy, yoga and guided imagery. For more on these therapies, visit the Complementary Therapies chapter. Joining a support group can ease some feelings of pain and provide other benefits. For more on support groups and other types of social support, visit the Support chapter.

Issues for Family Members and Other Co-survivors

Pain can affect entire families. It can be upsetting for co-survivors (spouses, partners, family members and other support persons) to know that 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 organizations such as the American Cancer Society offer support programs for spouses, partners, family members and other co-survivors. For more on these programs, visit the Support chapter. For more information for co-survivors, see Friends and Family.

For more on pain management, visit the American Society of Clinical Oncology's People Living with Cancer website.

Care After Treatment Ends

At some point, treatment may be stopped. This can happen when treatment stops showing any benefit or when it greatly affects quality of life.

Once treatment is stopped, reducing any symptoms caused by the cancer (palliation) becomes the main focus, rather than just a part of the treatment regimen. This can be a very difficult time for you and your family. Most health care providers or hospitals can arrange for counseling or support groups to help you address and manage the feelings and emotions that come with this stage of cancer care. For more on support, including hospice care, visit the Support chapter.

Updated 10/22/09 
 

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