Management of Pain Related to Metastatic Breast Cancer

This section discusses pain management for metastatic (also called advanced or stage IV) breast cancer.  

Learn more about the management of pain related to the treatment of early 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 cancer, it is crucial. If you are living with metastatic breast cancer, don’t 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 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 therapy (to limit side effects). This allows you to get the most benefit from the treatments aimed at reducing your cancer.

Pain control and palliation for metastatic breast cancer

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 may feel 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 you first have it. Waiting until pain is severe before seeking relief can make the pain harder to control and require more medication. Sometimes treatment plans can be changed to reduce painful side effects, so it is important to tell your health care provider about any pain 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. Your provider will likely change the type and dose of pain medication throughout your care. He/she may also suggest other 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.

Some providers are more experienced at treating pain than others. If your provider is unable to control your pain or if you are having side effects from the pain medications, you should ask for a referral to a palliative (PAY-lee-uh-tiv) care or pain specialist.

Palliative care specialists (physicians and nurses) can treat all people with cancer, not just those with advanced cancer. Palliative medicine is a medical specialty, just like oncology. Most cancer centers have a palliative care specialist as part of their treatment team. And, your oncologist will likely know of a palliative care specialist in your area.

For a list of pain management centers 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 ensures they can offer you the best pain management possible. Certain types of pain respond better to certain types of treatment.

Providers will often ask questions to learn more about your pain so they can choose the best treatment for you (see below). Pain may change as time goes on and it is important to let your providers know about these changes so 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. How intense is the pain (mild, moderate, severe, etc. or, 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 OK to you?
7. Describe the pain (throbbing, burning, tingling, pressure, etc.).
8. Does the pain come and go or do you feel it all the time?
9. Does the pain affect your ability to perform or enjoy daily activities?
10. Does the pain interfere with your sleep? Your appetite? Does it affect your mood?
11. What do you think is causing the pain?
12. 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 pain medications do not work?
3. What side effects may happen with the pain medications?
4. What can be done to manage these side effects?
5. What side effects do I need to report to you (the health care provider)?
6. What other options do I have for pain control?

(Adapted from World Health Organization, National Comprehensive Cancer Network, American Cancer Society and National Cancer Institute materials [42-45].)

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 (see Figure 5.12).  

Figure 5.12. 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 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 the first drug treatments (see below), a drug combination that has an anesthetic (to relieve pain) and a steroid (to reduce swelling) can be injected into or around a nerve to block pain. In some cases, this drug combination is injected into the fluid around the spinal cord to block the pain.

Bone pain

When cancer spreads to the bones (bone metastases), it can greatly affect quality of life.

Bone strengthening drug therapy

Part of standard treatment for bone metastases is bone strengthening therapy. Two types of drugs that can help strengthen bones are:

• Bisphosphonates (zoledronic acid (Zometa) or pamidronate (Aredia))
• RANK ligand (RANKL) inhibitor (denosumab (Xgeva))

Bisphosphonates or denosumab given through an IV once a month can lower the risk of fractures related to bone metastases and can help reduce pain caused by bone metastases. These drugs can also reduce the need for radiation therapy and surgery related to bone fractures and bone pain.  

Some people taking bisphosphonates need to increase their intake of vitamin D and calcium. If you develop muscle twitching or increased anxiety, ask your health care provider if you should take supplements to keep your calcium levels up.  

Though rare, a serious jawbone disorder called osteonecrosis may occur in some people who take bisphosphonates. It is important to have a dental exam prior to starting treatment with bisphosphonates [28].

Radiation therapy and surgery

Radiation therapy and surgery can 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 through an IV 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 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.  

Learn more about treating lymphedema.  

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

Non-opioid drugs

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) 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 you can get most non-opioid drugs without a prescription, check with your provider before taking them.

Opioid drugs

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

Some opioid medications contain both opioid and non-opioid drugs. For example, Percocet contains acetaminophen and oxycodone (an opioid). To ensure you do not take too much of the non-opioid drug, 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 5.13. 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 opioids almost always causes side effects, especially constipation. Your health care provider can help you prevent or control these symptoms so 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. If you have itching or a rash, it may be a sign of an allergic reaction to opioids. Tell your provider and he/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 [45].

Fear of addiction

Health care providers are careful to monitor the amount of opioids they are prescribing so 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 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 the drug and can be related to harmful behavior. Addiction among people taking opioids for pain management of cancer is very rare [45].

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® supports efforts to reduce policy barriers and promote effective state policies that ensure adequate pain management for people living with cancer. The good news is many states are adopting policies that improve access to pain management for people living with cancer, and steady progress continues towards these efforts.

Other medications used to treat metastatic breast cancer pain

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.

Figure 5.14. Other medications used to treat metastatic breast cancer pain 

How pain medications are given

There are many ways to take pain medications. Most are pills taken by mouth. For people who have trouble swallowing pills, some are available in liquid form or a special form that dissolves inside the cheek. A few pain relievers can be taken in the form of rectal suppositories. Fentanyl comes 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 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 medications described above or their side effects are too severe. In these cases, an implanted catheter can deliver the medications continuously into the fluid around the spinal cord. The catheter is connected to a small, computerized pump containing the pain medications. This pump is either implanted under the skin or is carried outside the body in a backpack or "fanny pack". These special 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.

Integrative and complementary therapies (non-drug therapies) for pain

There are many non-drug therapies you may choose to use along with pain medications. These include physical therapy, acupuncture, nutrition, relaxation techniques, massage therapy, hot and cold therapy, yoga and guided imagery. Learn more about these integrative and complementary 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.

Issues for family members and other co-survivors

Pain can affect the whole family. It can be upsetting for co-survivors (spouses, partners, family members and other support persons) 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 these programs.

Find more information for co-survivors.   

Care after treatment ends  

At some point, treatment for metastatic breast cancer 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 treatment.

This can be a very difficult time for you and your family. Your health care 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. 

For more on support groups, hospice and other types of support, visit the Support section.

*Please note, the information provided within Komen Perspectives articles is only current as of the date of posting. Therefore, some information may be out of date at this time.  

Updated 05/14/13